CPA 4

DKA: Clinical Presentation (What it looks like)

**Blood glucose >250 (Usually >625 and <1000) Kussmaul Respirations** Acetone breath Coma or change in LOC Total body deficit of K+ (May have false normal) Ketone/GLucose in urine Dehyrdration of 6L Metabolic acidosis**, pH <7.3 FLushed, dry skin Polyuria, plydipsia, Polyphagia N/V Weight Loss (Profound)

Burns: Intraabdominal Hypertension

**Serial IAP measurements via bladder pressure are performed on pt with: 40%< burns* 20% burns with inhalation* With fluid resuscitation greater than expected* Symptoms:** tense abdomen Decreasing UA output Elevated airway pressure Hypercapnea Hypoxemia

Burns: Wound Care

*Topical Antimicrobial Autograft* creates partial thickness wound from site* Premedicate before movement* ROM active and passive* Bandage fingers and toes individually* Splint extremeties extended while pt is resting to prevent contractures* Allograft/homograft = Temporary*, from person Xenograft = Temporary, from animal* Sheet nonmeched graft = over joint, face, hands* Compression used to decrease scars (Keloids)*

Golden Hour in Trauma

1st hour of emergent care focusing on rapid asssessment, resuscitation, and tx

A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible non-burn injured skin disorder? a. Toxic epidermal necrolysis b. Staphylococcal scalded skin syndrome c. Necrotizing soft tissue infection d. Graft versus host disease

A

Burns: Parkland Forumula

4mL x kg x % burned** Give half in first 8 hrs* Give second half over 16 hrs* Use LR first 24 hrs then can switch to D5W

Compartment Syndrome: Neuro Assessment

5 P's: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia*** Increasing throbbing pain not relieved with narcotics*

DKA: Glucose Reduction Goals

50-75/hr reduction = 75mg/dL** **If you decrease glucose too fast causes cerebral edema=death Serum K+ >3.3** Monitor stress and psychosocial issues

16. The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to: a. remove the patient's clothes and flush the area with water. b. apply saline compresses. c. contact a poison control center for directions on neutralizing agents. d. remove all jewelry.

A

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a. Central nervous system deficits b. Contractures c. Infection d. Stress ulcers

A

5. Which complications may manifest after an electrical injury? (Select all that apply.) a. Long bone fractures b. Cardiac dysrhythmias c. Hypertension d. Compartment syndrome of extremities e. Dark brown urine f. Peptic ulcer disease g. Acute cataract formation h. Seizures

A, B, D, E, G, H

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration.

A, B, C

6. An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.) a. involves a joint. b. involves the face, hands, or feet. c. is infected. d. requires more than 2 weeks for healing.

A, B, D

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages

A, B, D

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management.

A, C, E

23. The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? a. Use tweezers to remove any remaining ticks. b. Check the vital signs, including temperature. c. Give doxycycline (Vibramycin) 100 mg orally. d. Obtain information about recent outdoor activities.

ANS: A Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release. DIF: Cognitive Level: Apply (application) REF: 1697 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. A 74-year-old with palpitations and chest pain b. A 43-year-old complaining of 7/10 abdominal pain c. A 21-year-old with multiple fractures of the face and jaw d. A 37-year-old with a misaligned left leg with intact pulses

ANS: C, A, B, D The highest priority is to assess the 21-year-old patient for airway obstruction, which is the most life-threatening injury. The 74-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-year-old appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury. DIF: Cognitive Level: Analyze (analysis) REF: 1676 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. A 20-year-old patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine (Mucomyst). b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.

ANS: A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning. DIF: Cognitive Level: Understand (comprehension) REF: 1689 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

9. When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of a. vaccine. b. atropine. c. antibiotics. d. whole blood.

ANS: A Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox. DIF: Cognitive Level: Understand (comprehension) REF: 1690 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

20. Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a black tag d. A patient with a yellow tag

ANS: A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die. DIF: Cognitive Level: Remember (knowledge) REF: 1692 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

11. When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? a. "Do you feel safe in your home?" b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."

ANS: A The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. A social worker may be appropriate once further assessment is completed. DIF: Cognitive Level: Apply (application) REF: 1682 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

13. A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to a. assess the patient's current vital signs. b. give acetaminophen (Tylenol) per agency protocol. c. ask the patient to provide a clean-catch urine for urinalysis. d. tell the patient that it will 1 to 2 hours before being seen by the doctor.

ANS: A The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation. DIF: Cognitive Level: Apply (application) REF: 1675-1676 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Remove the patient's rings. b. Apply ice packs to both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.

ANS: A The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry. DIF: Cognitive Level: Apply (application) REF: 1687 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) 88/50, and pulse 112. The nurse initially will plan to a. apply wet sheets and a fan to the patient. b. provide O2 at 6 L/min with a nasal cannula. c. start lactated Ringer's solution at 1000 mL/hr. d. give acetaminophen (Tylenol) rectal suppository.

ANS: A The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr. DIF: Cognitive Level: Apply (application) REF: 1683 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

3. After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? a. Apply external cooling device. b. Check mental status every 15 minutes. c. Avoid the use of sedative medications. d. Rewarm if temperature is <91° F (32.8° C).

ANS: A When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not needed at this stage. Sedative medications are administered during therapeutic hypothermia. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)? a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Obtain an order to restrain the patient. e. Prepare to give sympathomimetic drugs.

ANS: A, B, C Cooling can produce dysrhythmias, so the patient's heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.

ANS: B Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. peritoneal lavage. b. abdominal ultrasonography. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).

ANS: B For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding. DIF: Cognitive Level: Apply (application) REF: 1678 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

16. Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first? a. Insert a large-bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.

ANS: B In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation. DIF: Cognitive Level: Apply (application) REF: 1689 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. ask about chronic medical conditions. d. attach a cardiac electrocardiogram monitor.

ANS: B The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

19. A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Heart rate b. Breath sounds c. Body temperature d. Level of consciousness

ANS: B The priority assessment relates to ABCs (airway, breathing, circulation) and how well the patient is oxygenating, so breath sounds should be assessed first. The other data will also be collected rapidly but are not as essential as the breath sounds. DIF: Cognitive Level: Apply (application) REF: 1685 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient? a. Atrial fibrillation b. Idioventricular rhythm c. Junctional rhythm d. Sinus bradycardia

a. Atrial fibrillation

21. Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. c. Ask the family members about whether they would prefer to remain in the patient's room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

ANS: C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences. DIF: Cognitive Level: Apply (application) REF: 1679 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

22. A 28-year-old patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? a. Prepare to administer rabies immune globulin (BayRab). b. Assist the health care provider with suturing of the bite wounds. c. Teach the patient the reason for the use of prophylactic antibiotics. d. Keep the wounds dry until the health care provider can assess them.

ANS: C Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms. DIF: Cognitive Level: Apply (application) REF: 1688 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

8. A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Auscultate heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d.

ANS: C Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient's admission diagnosis. DIF: Cognitive Level: Apply (application) REF: 1686 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

7. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? a. "I will take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I should drink sports drinks when working outside in hot weather." d. "I will move to a cool environment if I notice that I am feeling confused."

ANS: C Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action. DIF: Cognitive Level: Apply (application) REF: 1682 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

2. The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Continuously monitor heart rhythm. b. Check neurologic status every 2 hours. c. Place cooling blankets above and below patient. d. Give acetaminophen (Tylenol) 650 mg per nasogastric tube. e. Insert rectal temperature probe and attach to cooling blanket control panel.

ANS: C, D, E Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

10. When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which assessment indicates that the nurse should discontinue active rewarming? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).

ANS: D A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient. DIF: Cognitive Level: Apply (application) REF: 1686 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving a. tetanus immunoglobulin (TIG) only. b. TIG and tetanus-diphtheria toxoid (Td). c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

ANS: D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

14. The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses. b. A patient with an open femur fracture. c. A patient with bleeding facial lacerations. d. A patient with paradoxic chest movements.

ANS: D Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxic chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems. DIF: Cognitive Level: Apply (application) REF: 1676 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with a large-bore IV line.

ANS: D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. A 54-year-old patient arrives in the emergency department (ED) after exposure to powdered lime at work. Which action should the nurse take first? a. Obtain the patient's vital signs. b. Obtain a baseline complete blood count. c. Decontaminate the patient by showering with water. d. Brush off any visible powder on the skin and clothing.

ANS: D The initial action should be to protect staff members and decrease the patient's exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead any/all visible powder should be brushed off. The other actions can be done after the decontamination is completed. DIF: Cognitive Level: Apply (application) REF: 1690 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

DI: Clinical Presentation - Neurogenic only

Abrupt onset of polyuria

Tension Pneumothorax: Clinical Presentation

Absence of breath sounds on the affected side** Severe resp distress and chest pain Tracheal deviation Tachycardia and hypotension

Diabetes Insipidus (DI)

Absent or diminished release of ADH** from posterior pituitary = free water loss = osmolality and sodium to increase* 2 types: 1. Neurogenic 2. Nephrogenic**

HHS: Nursing Interventions

Airway and O2 #1 Fluid replacement same as DKA but more volume* Decrease CBG @ 75mg/dL slowly!!* K+ >3.3mEq/L** Insulin drip SUbcutaneous insulin when CBG is 200mg/dL** 50-75mg/dL/hr cbg reduction rate Monitor for fluid volume overload and cerebral edema (LOC, Lung sounds)

The nurse provides information to a patient who was exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement? A. "Anthrax can be spread by person-to-person contact." B. "It is not necessary to receive the anthrax vaccine." C. "An antibiotic will be prescribed for 2 months." D. "Antibiotics are only indicated for an active infection."

Answer: C. "An antibiotic will be prescribed for 2 months." Rationale: Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Anthrax is not spread by person-to-person contact; anthrax is spread by direct contact with the bacteria and its spores. The patient may receive the anthrax vaccine (three doses); if vaccinated, the course of antibiotic therapy is reduced to 30 days. Antibiotics are indicated after exposure to inhaled anthrax. Ch. 69

Which patient should the nurse prepare to transfer to a regional burn center? A. A 53-year-old patient with a chemical burn to the anterior chest and neck B. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% C. A 42-year-old patient who is scheduled for skin grafting of a burn wound D. A 39-year-old patient with a partial-thickness burn to the right upper arm

Answer: A. A 53-year-old patient with a chemical burn to the anterior chest and neck Rationale: The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criteria for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center; a burn to the right upper arm is 4% TBSA. Ch. 25

The nurse is caring for a 71 kg patient during the first 12 hours after a thermal burn injury. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation (select all that apply)? A. Heart rate is 94 beats/minute. B. Mean arterial pressure is 54 mm Hg. C. Urine output is 46 mL/hour. D. Urine specific gravity is 1.040. E. Systolic blood pressure 88 mm Hg

Answer: A. Heart rate is 94 beats/minute. C. Urine output is 46 mL/hour. Rationale: Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic blood pressure (BP) greater than 90 mm Hg, heart rate less than 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030. Ch. 25

A nurse manager educates the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse manager discuss with the staff? A. Learn the hospital emergency response plan. B. Report acts of violence to security personnel. C. Contact the American Red Cross for assistance. D. Notify local, state, and national authorities.

Answer: A. Learn the hospital emergency response plan. Rationale: All health care providers need to be prepared for a mass casualty incident; the priority responsibility is to know the agency's emergency response plan. Ch. 69

The nurse is planning to change the dressing covering a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer 30 minutes before the scheduled dressing change? A. zolpidem (Ambien) B. morphine sulfate C. sertraline (Zoloft) D. enoxaparin (Lovenox)

Answer: B. morphine sulfate Rationale: Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine sulfate is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents can also be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem promotes sleep; sertraline is an antidepressant; and enoxaparin is an anticoagulant. Ch. 25

The nurse is caring for a patient who sustained a deep partial thickness burn to the anterior chest area. Which statement would be appropriate for the nurse to include when documenting the appearance of this type of burn? ]A. Skin is hard with a dry, waxy white appearance with visible venous patterns. B. Skin blanches with pressure and is red with delayed blister formation. C. Skin is red and shiny with the presence of clear fluid-filled blisters. D. Skin is charred and leathery with visible muscles, tendons, and bones

Answer: C. Skin is red and shiny with the presence of clear fluid-filled blisters. Rationale: Deep partial thickness burns have fluid-filled vesicles that are red and shiny; may appear wet (if vesicles have ruptured); and mild to moderate edema may be present. Deep partial thickness burns result in severe pain related to nerve injury. Superficial partial thickness burns are red and blanch with pressure; pain and mild edema are present. Superficial partial thickness burns may have vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard; thrombosed vessels may be visible. Full-thickness burns result in an insensitivity to pain because of nerve destruction, and there may be involvement of muscles, tendons, and bones. Ch. 25

A patient arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask? A. Have you tried to commit suicide before? B. Do you feel like you have a fever? C. What time did you take the Tylenol? D. Are you experiencing any abdominal pain?

Answer: C. What time did you take the Tylenol? Rationale: Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons. Ch. 69

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Assist the patient to a high Fowler's position. B. Teach the patient deep breathing exercises. C. Allow the patient to verbalize feelings. D. Administer 100% humidified oxygen.

Answer: D. Administer 100% humidified oxygen. Rationale: Carbon monoxide (CO) poisoning may occur in house fires; CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as emergent as oxygen administration. Ch. 25

A patient is admitted to the emergency department with cold exposure and a core body temperature of 86.6o F (30.3o C). Which action is most appropriate for the nurse to take? A. Immerse the extremities in a water bath (102° to 108° F) [38.9° to 42.2° C]) B. Place an air-filled warming blanket on the patient. C. Position patient under a radiant heat lamp. D. Administer warmed intravenous (IV) fluids.

Answer: D. Administer warmed intravenous (IV) fluids. Rationale: A patient with a core body temperature of 86.6o F (30.3o C) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4° F [43° C]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite. Ch. 69

A nurse is performing triage in the emergency department. Which patient should the nurse see first? A. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg. B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. C. 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath. D. 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg.

Answer: B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. Rationale: Patient with drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last. Ch. 69

Basilar Skull Fracture

Assess for Battle sign (bruising behind ear) Cerebrospinal fluid may be present No NG tube!

14. The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following? a. Maintain a closed wound system to decrease the risk of infection. b. Remove excessive wound fluid and promote moist wound healing. c. Increase patient mobility with large burn wounds. d. Quantify wound drainage amount for more accurate output assessment.

B

19. The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals? a. "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal." b. "Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal." c. "It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster." d. "Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing."

B

20. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for: a. acute delirium. b. posttraumatic stress disorder. c. suicidal intentions. d. bipolar disorder.

B

A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to: a. excessive alcohol use. b. methamphetamine use. c. posttraumatic stress disorder. d. subacute delirium.

B

A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a. chemical burn b. electrical burn c. heat burn d. infection

B

An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patient's burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred.

B

Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied? a. Arm b. Face c. Leg d. Chest

B

Silver is used as an ingredient in many burn dressings because it: a. stimulates tissue granulation. b. is effective against a wide spectrum of wound pathogens. c. provides topical pain relief. d. stimulates wound healing.

B

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is : a. Keeping the extremity in a dependent position b. Active and passive range of motion every hour. c. Preparing for an escharotomy as a prophylactic measure d. Splinting the forearm

B

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is: a. altered nutrition, less than body requirements. b. body image disturbance. c. decreased cardiac output. d. fluid volume deficit.

B

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a. Carbon monoxide poisoning always occurs when soot is visible. b. Inhalation injury above the glottis may cause significant edema that obstructs the airway. c. The patient will have a copious amount of mucus that will need to be suctioned. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

B

Thyroid Storm: Nursing Interventions

Beta Blockers* High-Dose glucocorticoid Cool, quiet environment, low stim High cal high protein diet Tx fever = tylenol, cooling blankets, ice packs Potassium Iodide, propylthiouracil to stop T cell conversions* O2 supportive therapy

Blast Injury

Blunt, penetrating trauma Organ injury Gas organ injury (eardrums, lungs, intestines) Primary: Change in air pressure causing tissue damage (Shock wave) Secondary: Debris impale the body Tertiary: Body thrown by force=Blunt trauma Quarternary: Chemical, thermal, Bio exposure

When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first? a. Apical pulse b. Lung sounds c. Body temperature d. Level of consciousness

B The priority assessment data are how well the patient is oxygenating, so lung sounds should be assessed first. The other data also will be collected rapidly but are not as essential as the lung sounds.

Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) a. Burn injury less than 10% b. Bedrest c. Burns to lower extremities d. Electrical burn injury e. Delayed fluid resuscitation

B, C, E

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for: a. acute kidney injury. b. acute respiratory distress syndrome. c. intraabdominal hypertension. d. disseminated intravascular coagulation disorder.

C

In patients with extensive burns, edema occurs in both burned and unburned areas because of: a. catecholamine-induced vasoconstriction. b. decreased glomerular filtration. c. increased capillary permeability. d. loss of integument barrier.

C

The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a. 2800 mL b. 7000 mL c. 14 L d. 28L

C

The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a. "Do you live alone?" b. "Do you have any drug or food allergies?" c. "Do you have a heart condition or heart failure?" d. "Have you had any surgeries?"

C

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is: a. blood urea nitrogen. b. daily weight. c. hourly intake and urine output. d. serum potassium.

C

The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurse's best response would be: a. "Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound." b. "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." c. "Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." d. "Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound."

C

Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for: a. acute kidney injury. b. acute respiratory distress syndrome. c. infection. d. stress ulcers.

C

ESI Triage

Categorizes pt into most critical tx first <15 sec assess 5 level triage Incorporates illness severity, Resources, impending death** Level 1= impending death* Level 5= stubbed toe, Upper resp infection

The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment? a. A patient with absent pedal pulses b. A patient with an open femur fracture c. A patient with a sucking chest wound d. A patient with bleeding of facial lacerations

C Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid intervention but do not have airway or breathing problems.

Cervical Injury: Nursing Interventions

Maintain complete spinal immobilization* Prepare for cervical traction or halo device* Must stay immobilized until they go for surgery to be fused** Airway is priority, then O2 (Breathing), then immobilization** Have suction nearby in case of vomiting while strapped to board External Fixation - pin care, watch for infection** Halo brace** Do not under straps!!*

Burns: Electrical/Lightening Injury - Complications

Cardiac dysrhythmias* Cardiopulmonary arrest* Rhabdomyolysis = Myoglobulinuria* Compartment syndrome* Long bone fractures* Neuro deficit* Seizures* Associate with curling ulcers (peptic)** Acute Cataract Formation*

Burns: Rule of 9s

Chest is 9%* Trunk is 18%* Head is 9% Leg is 18% (one side) Arm is 9% (one side)

Pulmonary Contusion: Clinical Presentation

Chest wall abrasions or bruising* Signs of hypoxia on room air* Bloody secretions* Chest wall ecchymosis* Bruising of lung tissue*

Burns: Vacuum Assisted Closure Devices (VAC) NPWT (Neg Pressure Wound Therapy)

Creates negative-pressure dressing Remove wound fluid and provide a closed, moist wound healing environment* Stimulates perfusion* Earlier Re-epithelization*

Rhabdomyolysis: Risk Factors

Crush Injuries** Being struck by lightning* Anything that causes a lot of muscle damage** compartment syndrome burns Compromises Renal blood flow**

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to: a. hypervolemia from burn resuscitation. b. increased incidence of ureteral stones. c. nephrotoxic antibiotics for prevention of infection. d. release of myoglobin from injured tissues.

D

The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurse's knowledge of pain management for this patient? a. "Can we ask the music therapist to come by each morning to see if that will help the patient's pain? b. "The patient's pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock." c. "The patient's pain is often unrelieved. It would be best if we can schedule the opioids around the clock." d. "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"

D

The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because: a. intramuscular injections cause additional skin disruption. b. burn pain is so severe it requires relief by the fastest route available. c. hypermetabolism limits effectiveness of medications administered intramuscularly. d. tissue edema may interfere with drug absorption of injectable routes.

D

The correct priority order of actions in prehospital primary survey for burn injuries is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.) a. Assess ABCs and cervical spine. b. Provide oxygen therapy if smoke inhalation is suspected. c. Make rapid head-to-toe assessment to rule out additional trauma. d. Stop the burning process and prevent further injury.

D, A, B, C

Hypovolemia

Decreased cardiac output with trauma most often caused by hypovolemia from blood loss**

Burns: Chemical Burns

Deep every second, must be removed safely Dry chemicals= brush off then irrigate* Carefully remove clothing so not to spread agent* Methamphetamine injury is common** Call MSDS and do what they say****

Hypovolemia: Life-Threatening Blood Loss

Dr may request unmatched, type specific or O blood** O pos for adult male and females over 40** Will give medications with to control any possible reactions

Burns: SIlver Nitrate

Effective against wide spectrum of common wound pathogens**

Tension Pneumothorax

Emergency** Increased intrapleural and intrathoracic pressures= Compression of heart Can result in cardiovascular collapse

Burns: Inhalation Injury

Facial Burns Presence of soot around mouth and nose Singed nasal Hairs= airway swelling = intubate** Key is to protect airway and early intubation due to risk for edema***

Burns: Hands, Feet, Joints

Fingers and toes wrapped individually* Active or passive ROM to prevent atrophy, reduce shortening of ligaments, prevent contractures, decrease edema** Splinting and antideformity positioning are required to maintain function and prevent deformities of affected part**

Adrenal Crisis: Nursing Interventions

Fluid replacement with D5W and NS until hypovolemia stabilizes (5L in 1st 12-24 hrs) Pt education for preventing another crisis Meds: 1. Glucocorticoid replacement (Dexamethasone) 2. Pressors - Dopamine, norempinephrine

SIADH: Nursing Interventions

Fluid restriction 800-1000mL/day** Liberal salt and protein intake Gradual return to baseline - NS slow** Oral care (spit don't swallow) Seizure Precautions if NA+ <120 Pt education

Hypovolemia: Intraosseous Procedures

For fluid resuscitation If cannot get two large bore IV lines Can access in Sternum, legs, arms, or pelvis**

Pulmonary Contusion

From blunt or penetrating trauma to chest MVC** One of the most common causes of death after chest trauma Often results in ARDS** Long term vent, focus on pain relief Careful with fluid admin for pulmonary edema

DI: Clinical Presentation - Nephrogenic only

Gradual onset of polyuria Hypokalemia Hypercalcemia

Burns: Sign it was a meth lab

Hands, face burned Agitated Change story and does not match symptoms*

DI: Causes and Risk Factors - Nephrogenic

Hereditary Renal Diseae Drugs: ethanol, phnytoin, lithium, demeclocycline, methoxyflurane

Hyperosmotic Hyperglycemic State (HHS): RIsk Factors

High cal parenteral nutrition B-blockers, thiazide diuretics, CCBs, Phenytoin, Glucocorticoid, TPN Not enough fluid intake (Nursing home residents, Mentally disabled)** Major illness stress response* Type II DM initial presentation

Burns: ROM

Hourly for 5 mins Prevent edema

Thyroid Storm

Hyperthyroidism untreated Rare if normal thyroid gland

SIADH: Clinical Presentation (What it looks like)

Hyponatremia and hypo-osmolality*** Confusion HxA, seizures, coma Increased BP, CVP, and PAOP Increased RR, Dyspnea, crackles in lungs Frothy pink sputum Concentrated urine and decreased output UA sodium >20mEq/L Decreased BUN, Cr, and albumin Edema Increased ICP =Hypervolemia

Hypovolemia: Complications

Hypothermia - Prevent by warming fluids** Coagulopathies - Citrate in banked blood may induce hypocalcemia** Avoid massive transfusions

DI: Causes and Risk Factors - Neurogenic

Idiopathic (congenital or autoimmune) Intracranial surgery Head trauma** Increased ICP Damage to pituitary or hypothalamus gland

Tension Pneumothorax: Nursing Interventions

Immediate decompression with needle thoracostomy** Prepare for chest tube insertion on affected side**

DKA: Risk factors

Infections Initial presentation of type I DM Stress from surgery or trauma Malfunction of insulin pump** Eating disorders** or stress eating Glucocorticoids Stress not allowing Sleep** Other: time management of taking insulin**, financial resources low (can't afford insulin)*

DKA: Fluid Replacement

Initial bolus of 1L of 0.9% NS** Add 5% Dextrose @ 250mL/dL when** plasma glucose level approaches 200mg/dL (prevent hypoglycemia and correct Ketosis) Target blood glucose reduction @ 75mg/dL (50-70/hr)** Serum K+ > 3.3mEq/L******

DKA: Potassium Goals

Keep between 4-5 mEq/L Must correct to prevent dysrrhythmias with fluid replacement

Nephrogenic DI

Kidney collecting ducts and distal tubules are unresponsive to ADH**** (ADH being produced by posterior pituitary but kidneys won't respond to it)

Myxedema: Nursing Interventions

Levothyroxine** (longer duration) Tx hypothermia** - warm room, passive warming with blankets=decrease metabolism Monitor gas exchange and resp status, tongue edema* ECG Decrease Sodium intake* No narcotics, must avoid resp depression

Adrenal Crisis

Life threatening absence of cortisol and aldosterone (corticosteroids)

Fat Embolism: Risk Factors

Long Bone injury** Multiple fractures = scenario with femur fracture**

Abdominal Trauma

Looks like: Pain in area or referred to shoulder (spleen), hypotension, costobertebral tenderness, hematuria, bruising over lower ribs, hemorrhage or shock to kidneys Tx: FAST**** Focused Assessment with Sonography for Trauma********

Adrenal Crisis: Clinical Presentation (What it looks like)

Low Na+ Hyperkalemia** Hypotension requiring vasopressors (Fluids won't work)** Hypovolemia** HxA and fatigue that worsens Severe fatigue LOC changes Hypoglycemia** Plasma cortisol <10mg/dL

Fat Embolism: Clinical Presentation

Low grade fever new onset tachycardia, dyspnea, increased Resp effort, and hypoxemia Petechial rash

HHS: Tx Goals

Meet two of the following: 1. pH >7.3 2. HC3O >15 mEq/L 3. Anion gap <12 mEq/L

Secondary Survey for Trauma

Methodical head-to-toe assessment FUll vitals, 5x interventions 1. ECG 2. SPO2 3. NG 4. Foley 5. Labs Hix Comfort Inspect back

Burns: Abdominal Compartment Syndrome

Monitor circumferential full-thickness burns**, can restrict breathing if on chest or abdomen* s/sx: tense abdomen, decrease urine, tachypnea, increased CO2, decreased O2* APP=MAP-IAP (intraabdominal pressure)**

Myxedema

Most life threatening form of hypothyroidism Opposite of Thyroid storm Coma Usually coincides with stressor (infection)** Usually elderly women Hypothermia**, stroke, trauma, critical illness

Hypothermia: Complications

Myocardial dysfunction* Coagulpathies (Calcium)* Reduced Perfusion* Dysrhythmias (PVCs cause death)* Risk for bleeding because cannot clot

DI: Nursing Interventions

NA restriction replace free water with hypotonic solutions of dextrose ADH preps for neurogenic Vasopressin and Desmopressin Pt teaching Volume replacement Monitor for fluid overload!!*

How is HHS different from DKA?

No ketosis higher levels of hyperglycemia (>1000)* Plasma osmolality about 350mOsm/kg* Greater body fluid devicit >9L** More profound LOC decrease (Coma)* Type II DM not TYpe I* Mild acidosis or not present* Absent DTRs** Positive Babinski sign**

Burns: Pain Management

Opiates IV in a higher than normal dosage** PCA* with basal rate Give pain meds before any dressing change or intervention Substance abuse will have higher tolerance and need higher drug amounts* (see a lot of burn patients that are alcoholics or abusers) Increased metabolism makes them not last as long* Pre-medicate** Anxiolytic

Adrenal Crisis: Cause and Risk Factors

Primary: (results in Addison's Dx) 1. Destruction of adrenal gland (90%) 2. TB, Hemorrhage, infection, HIV Secondary: 1. Abrupt w/drawal from steroids** 2. Systemic inflammatory states (sepsis, vasculitis, sickle cell) 3. Hypothalmic Disorders

DKA: Nursing Interventions

Priority=Airway #2 Breathing=respiratory support #3 Correct K+ to a high normal value! Fluid Replacement** Supportive measures

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Produce excess ADH Stimulation of hypothalamus or pituitary to secrete ADH. Inability to secrete a dilute urine, fluid retention, hyponatremia

Primary Survey for Trauma

Rapid 1-2 min* evaluation Baseline data - identify and correct life threatening problems* Airway with C-spine stabilization Breathing Circulation DIsability Exposure

Thyroid Storm: Clinical Presentation

Severe fever* up to 106 Marked Tachycardia* Increased CO* = AHF Decreased BP* Tachypnea* Hyperthermia (severe)* A. FIb. Muscle weakness and fatigue Cramps

Exposure of Pt to Radioactive Material (Primary Intervention)

Shower decontamination**

SIADH: Causes and Risk Factors

Small cell carcinoma of lung** Head injury or injury of hypothalamus or pituitary Malignancy near or of Hypothalamus or pituitary Cancer of prostate, pancreas, or duodenum Hodgkin's disease Viral Pneumonia TB, COPD Intracranial surgery Stroke Brain tumor

Fat Embolism: Tx

Stabilization of fractured extremities to minimize movement to prevent release of fat****

Heat Stroke: Tx

Stabilize ABC (100% O2 for hypermetabolic state, mechanical vent) Rapidly reduce temp** Cooling Methods**: 1. Remove clothing* 2. Cover with wet sheets* 3. Place pt in front of large fan* 4. Immerse in ice water bath* 5. Admin cool fluids or lavage with cool fluids*

Burns: Suspected Abuse

Suspicious burn marks must be reported* Separate pt from caregivers to assess*** Maintain patient safety

Burns: Electrical/Lightening Injury - Clinical Presentation

Tetanic muscle contraction Resp muscle paralysis* Cutaneous injury superficial Lightning = Cardiopulmonary arrest AC higher probability of cause cardiac arrest with V fib.**

Non Burn Dermal Injury: Clinical presentation

Toxic Epidermal Necrolysis (TEN) from* environmental agent* Stevens-Johnson Syndrome * Initial fever and flu-like symptoms* Erythema and blisters develop within 24-96 hrs**

How do you know if fluid replacement is working?

Urine output and BP stabilization (Outcomes are met!)* UA output 50-60 mL/hr

DI: Clinical Presentation (Both)

Urine s pale and dilute hypovolemia = hypotension, tachycardia, low CVP Low specific gravity Neuro changes (Hypernatremia) Concentrated urine high serum osmolality elevated BUN

Rhabdomyolysis: Fluid Resuscitation

Want to flush myoglobin from renal tubules Use osmotic diuretics and sodium bicarb with IV fluids Titrate IV fluids to achive UA output of 100-200 mL/hr****

Hypothermia: Tx

Warm trauma room* External heating device (force air warmer)* Warm fluids and blood products for rapid infusion** Transfusion with clotting factors** Watch Calcium*****

Burns: Risk for Infection

Wash hands* Aseptic Wound care* Combined IV and topical antibiotics* rotate topical sites Multiple invasive lines, IV, foley, ETT, take out at first available time to reduce chance of infection***

Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) a. ADH deficiency b. ADH excess c. ADH insensitivity d. ADH replacement therapy e. Water deprivation

a. ADH deficiency c. ADH insensitivity

Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.) a. Administer levothyroxine (Synthroid) as ordered. b. Encourage the intake of foods high in sodium. c. Initiate passive rewarming interventions. d. Monitor airway and respiratory effort. e. Monitor urine osmolality.

a. Administer levothyroxine (Synthroid) as ordered. c. Initiate passive rewarming interventions. d. Monitor airway and respiratory effort.

What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) a. Altered sleep/rest patterns b. Eating disorder c. Exposure to influenza d. High levels of stress e. Lack of financial resources

a. Altered sleep/rest patterns b. Eating disorder d. High levels of stress e. Lack of financial resources

The nurse is caring for a patient who suffered a head trauma following a fall. The patient's heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 1.8 mg/dL. The findings are consistent with which disorder? a. Cerebral salt wasting b. Diabetes insipidus c. Syndrome of inappropriate secretion of antidiuretic hormone d. Thyroid storm

a. Cerebral salt wasting

During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air e. Paradoxical chest wall movement

a. Chest wall ecchymosis c. Pink-tinged or blood secretions d. Signs of hypoxia on room air

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a. Crush injury to right arm b. Gunshot wound to the abdomen c. Lightning strike of the left arm and chest d. Pulmonary contusion and rib fracture e. Penetrating wound to both legs

a. Crush injury to right arm c. Lightning strike of the left arm and chest

Which of the following would be seen in a patient with myxedema coma? a. Decreased reflexes b. Hyperthermia c. Hyperventilation d. Tachycardia

a. Decreased reflexes

Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event? (Select all that apply.) a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. c. Limit visitation to set times throughout the day. d. Coordinate a family conference. e. Determine how the family perceives the event

a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. d. Coordinate a family conference. e. Determine how the family perceives the event

The trauma nurse understands which information related to the older trauma patient? (Select all that apply.) a. Falls are the leading cause of death in the older population. b. Physiologic capacity is an important predictor of outcome. c. Hypotension in the elderly can appear as normotension. d. Chronic diseases do not have much effect on the older trauma patient. e. Fractures to bones other than hips are uncommon from trauma.

a. Falls are the leading cause of death in the older population. b. Physiologic capacity is an important predictor of outcome. c. Hypotension in the elderly can appear as normotension.

A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this patient? a. He will go into adrenal crisis. b. He will go into thyroid storm. c. His autoimmune disease will go into remission. d. Nothing; it is appropriate to stop the medication for 3 days.

a. He will go into adrenal crisis.

Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) a. Heredity b. Medications, including phenytoin (Dilantin) and lithium carbonate c. Meningitis d. Pituitary tumors e. Sickle cell disease

a. Heredity b. Medications, including phenytoin (Dilantin) and lithium carbonate e. Sickle cell disease

Which of the following statements apply to trauma patients and their potential complications? (Select all that apply.) a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection.

a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation.

Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture? a. Insertion of a nasotracheal tube b. Insertion of an indwelling urinary catheter c. Endotracheal intubation d. Placement of an oral airway

a. Insertion of a nasotracheal tube

An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a. Level I b. Level II c. Level III d. Level IV

a. Level I

Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.) a. Mean arterial pressure 48 mm Hg b. Elevated serum blood alcohol level c. Nonreactive pupils d. Respiratory rate of 10 breaths/min e. Open skull fracture

a. Mean arterial pressure 48 mm Hg c. Nonreactive pupils d. Respiratory rate of 10 breaths/min e. Open skull fracture

The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a. Placement of an intraosseous catheter b. Placement of a central line c. Insertion of a femoral catheter by a trauma surgeon d. Rapid transfer to the operating room

a. Placement of an intraosseous catheter

Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered c. Administration of potassium as ordered d. Administration of calcium as ordered e. Monitoring CBC and coagulation studies

a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered d. Administration of calcium as ordered

A 20-year-old female with a history of type 1diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose648 mg/dL pH6.88 PaCO220 mm Hg PaO295 mm Hg HCO3- undetectable Anion gap>31 Na+127 mEq/L K+ 3.5 mEq/L Creatinine1.8 mg/dL After the patient's airway and ventilation have been established, the next priority for this patient is: a. administration of a 1-L normal saline fluid bolus. b. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. c. administration of 20 mEq KCl in 100 mL. d. IV push administration of 1 amp of sodium bicarbonate.

a. administration of a 1-L normal saline fluid bolus.

A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to a. assign the nurse administrative duties, such as obtaining patient demographic information. b. assign the nurse to a triage room with another nurse from the emergency department. c. thank the nurse but inform her to return to her department as her skill set is not a good match for patients' needs. d. have the nurse assist with transport of patients to procedural areas.

a. assign the nurse administrative duties, such as obtaining patient demographic information.

The nurse is caring for a 27-year-old patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing: a. diabetes insipidus. b. diabetic ketoacidosis. c. hyperosmolar hyperglycemic syndrome. d. syndrome of inappropriate secretion of antidiuretic hormone.

a. diabetes insipidus.

The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) a. 18-year-old male who has undergone surgical correction of a fractured femur b. 29-year-old female who is undergoing evaluation for pheochromocytoma c. 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) d. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e. 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)

b. 29-year-old female who is undergoing evaluation for pheochromocytoma c. 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) d. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e. 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)

Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a. A fall from a 6-foot ladder onto the grass b. A shotgun wound to the abdomen c. A knife wound to the right chest d. A motor vehicle crash in which the driver hits the steering wheel

b. A shotgun wound to the abdomen

A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the following? (Select all that apply.) a. Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL. b. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. c. Discontinue the insulin pump by removing the infusion set catheter. d. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. e. Perform blood glucose monitoring before exercising and driving.

b. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. d. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. e. Perform blood glucose monitoring before exercising and driving.

A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine (Lantus) and insulin aspart (NovoLog). How should the nurse manage this transition in insulin delivery? a. Administer the insulin glargine and continue the IV insulin infusion for 24 hours. b. Administer the insulin glargine and discontinue the IV infusion in several hours. c. Discontinue the IV infusion and administer the insulin aspart with the next meal. d. Discontinue the IV infusion and administer the Lantus insulin at bedtime.

b. Administer the insulin glargine and discontinue the IV infusion in several hours.

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) a. Blood glucose 43 mg/dL b. Blood glucose 524 mg/dL c. HCO3- 10 mEq/L d. PaCO2 37 mm Hg e. pH 7.23

b. Blood glucose 524 mg/dL c. HCO3- 10 mEq/L e. pH 7.23

It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. ARDS b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction e. Fat embolism

b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction

A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? a. Blood pressure 82/60 mm Hg, heart rate 122 beats/min, respiratory rate 28 breaths/min b. Crackles (rales) on auscultation of bilateral lung fields c. Responsive only to painful stimuli d. Irregular heart rate and rhythm

b. Crackles (rales) on auscultation of bilateral lung fields

Which of the following statements about mass casualty triage during a disaster is true? a. Priority treatments and interventions focus primarily on young victims. b. Disaster victims with the greatest chances for survival receive priority for treatment. c. Once interventions have been initiated, health care providers cannot stop the treatment of disaster victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.

b. Disaster victims with the greatest chances for survival receive priority for treatment.

An individual with type 2 diabetes who takes glipizide (Glucotrol) to control her blood glucose has begun a formal exercise program at a local gym. While exercising on the treadmill, she becomes pale, diaphoretic, and shaky. She has a headache and feels as though she is going to pass out. What is the individual's priority action? a. Drink additional water to prevent dehydration. b. Eat something with 15 g of simple carbohydrates. c. Go to the first aid station to have glucose checked. d. Take another dose of the oral agent.

b. Eat something with 15 g of simple carbohydrates.

Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? a. Activity intolerance b. Fluid volume deficient c. Hyperthermia d. Impaired nutrition, more than body requirements

b. Fluid volume deficient

The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following? a. Congestive heart failure b. Hypovolemic shock c. Infection d. Volume overload

b. Hypovolemic shock

Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully crossmatched blood products are administered. e. Hypertonic saline solutions are often used during initial resuscitation.

b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes

When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident? a. High-speed motor vehicle crashes b. Poisonings from prescription or illegal drugs c. Violent or domestic traumatic altercations d. Work-related falls

b. Poisonings from prescription or illegal drugs

Acute adrenal crisis is caused by: a. acute renal failure. b. deficiency of corticosteroids. c. high doses of corticosteroids. d. overdose of testosterone.

b. deficiency of corticosteroids.

A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of: a. adrenal insufficiency. b. diabetic ketoacidosis. c. hyperosmolar, hyperglycemic state. d. hypoglycemia.

b. diabetic ketoacidosis.

During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent a. disseminated intravascular coagulation. b. multisystem organ dysfunction. c. septic shock. d. wound infection.

b. multisystem organ dysfunction.

Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent a. catheter-associated infection. b. venous thromboembolism. c. fat embolism. d. nosocomial pneumonia.

b. venous thromboembolism.

Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a. 30 mL/hr. b. 50 mL/hr. c. 100 mL/hr. d. 300 mL/hr.

c. 100 mL/hr.

Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a. A patient who has a closed head injury with a decreased level of consciousness b. A patient who has a fractured femur and is currently in traction c. A patient who has received large volumes of fluid and/or blood replacement d. A patient who has underlying chronic obstructive pulmonary disease

c. A patient who has received large volumes of fluid and/or blood replacement

Which of the following best defines the term traumatic injury? a. All trauma patients can be successfully rehabilitated. b. Traumatic injuries cause more deaths than heart disease and cancer. c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d. Trauma mainly affects the older adult population.

c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events.

A 32-year-old patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? a. Calcium b. Chloride c. Potassium d. Sodium.

c. Potassium

The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient smells of alcohol and begins to vomit in the ED. Which of the following interventions is most appropriate? a. Insert an oral airway to prevent aspiration and to protect the airway. b. Offer the patient an emesis basin so that you can measure the amount of emesis. c. Prepare to suction the oropharynx while maintaining cervical spine immobilization. d. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

c. Prepare to suction the oropharynx while maintaining cervical spine immobilization.

The nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse include in this transfusion protocol? (Select all that apply.) a. Whole blood b. Universal donor blood only c. Red blood cells d. Platelets e. Plasma

c. Red blood cells d. Platelets e. Plasma

Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? a. Fasting blood glucose 156 mg/dL b. Serum potassium 5.8 mEq/L c. Serum sodium 115 mEq/L d. Serum sodium 152 mEq/L

c. Serum sodium 115 mEq/L

The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is: a. 70 to 120 mg/dL. b. a decrease of 25 to 50 mg/dL compared with admitting values. c. a decrease of 50 to 75 mg/dL compared with admitting values. d. less than 200 mg/dL.

c. a decrease of 50 to 75 mg/dL compared with admitting values.

A near-infrared spectroscopy (NIRS) probe is placed in a trauma patient during the resuscitation phase to: a. assess severity of metabolic acidosis. b. determine intraperitoneal bleeding. c. determine tissue oxygenation. d. prevent complications of over-resuscitation.

c. determine tissue oxygenation.

A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include: a. administration of 3% normal saline. b. administration of exogenous vasopressin. c. fluid restriction. d. low sodium diet.

c. fluid restriction.

The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte balance is: a. fluid volume excess. b. hyperglycemia. c. hyperkalemia d. hypernatremia

c. hyperkalemia

In the trauma patient, symptoms of decreased cardiac output are most commonly caused by a. cardiac contusion. b. cardiogenic shock. c. hypovolemia. d. pericardial tamponade.

c. hypovolemia.

A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED a. includes a cervical spine x-ray study to determine the presence of a fracture. b. involves turning the patient from side to side to get a look at his back. c. is done quickly in the first few minutes to get a baseline assessment and establish priorities. d. is a methodical head-to-toe assessment identifying injuries and treatment priorities.

c. is done quickly in the first few minutes to get a baseline assessment and establish priorities.

The nurse is providing postoperative care to a patient who underwent a transsphenoidal hypophysectomy for a benign pituitary tumor. The nurse administers replacement hydrocortisone, thyroid hormone, and vasopressin. The nurse evaluates that the vasopressin replacement is effective when: a. the patient's blood glucose is 110 mg/dL. b. the patient maintains a core body temperature of 98.2° F (36.8° C). c. the patient's urine specific gravity decreases. d. 2 liters of urine are produced in a 24-hour period.

d. 2 liters of urine are produced in a 24-hour period.

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? a. An 18-year-old college student with type 1 diabetes who exercises excessively b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza

d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza

An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis? a. Elevated adrenocorticotropic hormone b. Elevated cortisol levels c. Elevated T3 and T4 d. Elevated thyroid-stimulating hormone

d. Elevated thyroid-stimulating hormone

In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis

d. Higher serum glucose, higher osmolality, and no ketosis

The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels

d. Serum lactate levels

Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a. Absence of pulse in affected extremity b. Pallor in the affected area c. Paresthesia in the affected area d. Severe, throbbing pain in the affected area

d. Severe, throbbing pain in the affected area

Which of the following interventions is a strategy to prevent fat embolism syndrome? a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with low-molecular weight heparin. d. Stabilize extremity fractures early.

d. Stabilize extremity fractures early.

A patient has been admitted to the emergency department with a massive hemothorax. What action by the nurse takes priority? a. Place the patient on a cardiac monitor b. Prepare for rapid intubation c. Seal the wound with occlusive dressings d. Start 2 large bore IVs

d. Start 2 large bore IVs

A patient presents to the emergency department (ED) with the following clinical signs: Pulse: 132 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 32 breaths/min Temperature: 104.8° F Chest x-ray: Findings consistent with congestive heart failure Cardiac rhythm: Atrial fibrillation with rapid ventricular response These signs are consistent with which disorder? a. Adrenal crisis b. Myxedema coma c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) d. Thyroid storm

d. Thyroid storm

The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition? a. Daily weight b. Fingerstick glucose c. Lung sound auscultation d. Urine osmolality

d. Urine osmolality

Which of the following statements is true about the medical management of diabetic ketoacidosis? a. Serum lactate levels are used to guide insulin administration. b. Sodium bicarbonate is a first-line medication for treatment. c. The degree of acidosis is assessed through continuous pulse oximetry. d. Volume replacement and insulin infusion often correct the acidosis.

d. Volume replacement and insulin infusion often correct the acidosis.

In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started? a. Never; normal saline is the only appropriate solution in diabetes management b. When the blood sugar reaches 70 mg/dL c. When the blood sugar reaches 150 mg/dL d. When the blood glucose reaches 250 mg/dL

d. When the blood glucose reaches 250 mg/dL

The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the provider and anticipates a. administration of lactated Ringer's solution (1 L) wide open. b. chest x-ray study to determine the etiology of the symptoms. c. endotracheal intubation and mechanical ventilation. d. needle thoracostomy and chest tube insertion.

d. needle thoracostomy and chest tube insertion.

Which of the following laboratory values would be more common in patients with diabetic ketoacidosis? a. Blood glucose >1000 mg/dL b. Negative ketones in the urine c. Normal anion gap d. pH 7.24

d. pH 7.24

The nurse is providing insulin education for an elderly patient with longstanding diabetes. An order has been written for the patient to take 20 units of insulin glargine (Lantus) at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is: a. 0200. b. 0400. c. 0800. d. peakless.

d. peakless.

A patient is admitted to the oncology unit with a small cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with: a. adrenal crisis. b. diabetes insipidus. c. myxedema coma. d. syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

d. syndrome of inappropriate secretion of antidiuretic hormone (SIADH).