Critical Exam 4

In which order would the nurse take these actions when a client arrives in the emergency department with burns of the chest? -Insert an intravenous (IV) catheter. -Calculate the extent of the client's burns. -Cover the client with a warm blanket. -Assess the client's respiratory rate.

-Assess the client's respiratory rate. -Insert an intravenous (IV) catheter. -Cover the client with a warm blanket. -Calculate the extent of the client's burns.

A patient is prescribed warfarin following a deep venous thrombosis and pulmonary embolism. Which information would the nurse include in the teaching plan? Select all that apply. -Eliminate green vegetables from the diet. -Do not take ibuprofen or aspirin unless prescribed. -Use a soft toothbrush and observe the gums for bleeding. -Wear a bracelet that identifies that the patient is taking an anticoagulant. -Blood coagulation testing is needed only for the first four to six weeks of therapy.

-Do not take ibuprofen or aspirin unless prescribed. -Use a soft toothbrush and observe the gums for bleeding. -Wear a bracelet that identifies that the patient is taking an anticoagulant.

Which precautions would the nurse take when suctioning a tracheostomy? -Limit suction time to 30 seconds. -Rinse the catheter with clean water between suction passes. -Monitor oxygen saturation and lung sounds after suctioning. -Apply suction when inserting the catheter into the tracheostomy.

-Monitor oxygen saturation and lung sounds after suctioning.

The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow? -High caloric intake, liberal potassium intake, and 3 g protein/kg per day -High caloric intake, restricted potassium intake, and 1 g protein/kg per day -Moderate caloric intake, liberal potassium intake, and 3 g protein/kg per day -Moderate caloric intake, restricted potassium intake, and 1 g protein/kg per day

-High caloric intake, liberal potassium intake, and 3 g protein/kg per day

Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct. -Monitoring vital signs -Cutting off the clothing -Inserting a urinary catheter -Removing the client's jewelry -Establishing an intravenous line

-Monitoring vital signs -Cutting off the clothing -Inserting a urinary catheter -Removing the client's jewelry -Establishing an intravenous line

A client undergoes a subtotal gastrectomy. After surgery the client begins to hemorrhage. Which clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. One, some, or all responses may be correct. -Oliguria -Bradypnea -Diaphoresis -Tachycardia -Hypertension

-Oliguria -Diaphoresis -Tachycardia

When a client with hypovolemic shock has a hematocrit value of 25%, which fluid therapy will the nurse prepare to infuse? -Lactated Ringer solution -Human serum albumin 5% -Packed red blood cells -High molecular weight dextran

-Packed red blood cells

Which clinical findings would the nurse expect when assessing a client who has cardiogenic shock? Select all that apply. One, some, or all responses may be correct. -Pallor -Agitation -Tachycardia -Narrow pulse pressure -Decreased respirations

-Pallor -Agitation -Tachycardia -Narrow pulse pressure

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall? -Partial-thickness burns require grafting before they can heal. -Partial-thickness burns are often painful, reddened, and have blisters. -Partial-thickness burns cause destruction of both the epidermis and dermis. -Partial-thickness burns often take months of extensive treatment before healing.

-Partial-thickness burns are often painful, reddened, and have blisters.

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? -Decreased rate of glomerular filtration -Excessive blood loss through the burned tissues -Plasma proteins moving out of the intravascular compartment -Sodium retention occurring as a result of the aldosterone mechanism

-Plasma proteins moving out of the intravascular compartment

When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? Select all that apply. -Pregnancy -Pneumonia -Cancer -Oral contraceptive use -Hormone therapy

-Pregnancy -Cancer -Oral contraceptive use -Hormone therapy

Which action would the nurse perform immediately for a patient with acute pancreatitis who develops acute respiratory distress syndrome (ARDS)? -Infuse normal saline. -Give chest compressions. -Provide ventilatory support. -Schedule a portable chest x-ray.

-Provide ventilatory support.

A patient with metastatic lung cancer is suspected to have malnutrition. The nurse reviews the results of the serum albumin and serum prealbumin laboratory studies. How does the nurse interpret the findings? -If the albumin level is normal, then the patient does not have protein malnutrition. -The albumin level is an excellent indicator of acute changes in nutritional status. -Decreased levels of both indicate that malnutrition is present. -The prealbumin level more accurately reflects the patient's nutritional status.

-The prealbumin level more accurately reflects the patient's nutritional status.

A client with burns over 35% of the body reports chilling. Which action will the nurse take to promote client comfort? -Limit room drafts. -Place a sterile top sheet over the client. -Decrease the room humidity to less than 10%. -Maintain an 80°F (26.7°C) room temperature.

-Limit room drafts.

The nurse is caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the priority during the emergent phase of this injury? -Preventing pain -Managing leukopenia -Preventing infection -Managing fluid loss

-Managing fluid loss

Which specific emergency burn management would be appropriate for a client hospitalized with burns caused by flames? -Removing all metal objects -Helping the client bathe or shower -Initiating cardiopulmonary resuscitation -Administering tetanus toxoid for prophylaxis

-Removing all metal objects

Which is a primary clinical manifestation of flail chest in an unconscious patient? -Cyanosis -Shallow respirations -Neck vein distention -Decreased heart rate

-Shallow respirations

A firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, the nurse identifies tachycardia, tachypnea, and dyspnea. The nurse auscultates the client's lungs and expects to hear which type of breath sound? -Stridor -Rhonchi -Crackles -Wheezes

-Stridor

Which clinical manifestations would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? Select all that apply. One, some, or all responses may be correct. -Tachycardia -Restlessness -Warm, moist skin -Decreased urinary output -Bradypnea

-Tachycardia -Restlessness -Decreased urinary output

The nurse is caring for a client with severe burns 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? -Milk -Tea -Orange juice -Tomato juice

-Tea

How would the nurse classify burns that are painful, red to white, and edematous? -Eschar -Deep full-thickness burns -Deep partial-thickness burns -Superficial partial-thickness burns

-Deep partial-thickness burns

A client sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention but the client refuses. The nurse would instruct the client to go see a primary health care provider if which change occurs? -Blisters appear -Urinary output decreases -Edema and redness occur -White patches develop

-Urinary output decreases

Which action will the nurse take when caring for a patient with acute respiratory failure due to left-sided pneumonia? -Suction the patient every hour. -Avoid hyperventilating the patient. -Position the patient with the good lung up. -Use huff coughing to help to clear secretions.

-Use huff coughing to help to clear secretions.

Which action would the nurse take when caring for a client with burns who is being treated with collagenase and polysporin powder therapy? -Apply the treatment twice a day. -Monitor arterial blood gas levels. -Use the treatment on partial-thickness wounds with eschar. -Avoid a barrier dressing such as occlusive petrolatum gauze

-Use the treatment on partial-thickness wounds with eschar.

A client admitted with severe burns, obesity, and with preexisting respiratory problems is at risk for which complication? -Necrosis -Pneumonia -Dysrhythmias -Venous thromboembolism

-Venous thromboembolism

Which rationales are used to explain the need for humidification of air for a patient who has a tracheostomy? Select all that apply. -Warms secretions -Moisturizes secretions -Decreases risk for stoma infection -Prevents formation of mucous plugs -Aids in the prevention of tracheal necrosis

-Warms secretions -Moisturizes secretions -Prevents formation of mucous plugs

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; PO2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition would the nurse suspect the client has based on these findings? -Azotemia -Hypokalemia -Metabolic alkalosis -Respiratory alkalosis

-Azotemia

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply. One, some, or all responses may be correct. -Bradycardia -Hypotension -Spastic paralysis -Urinary retention -Increased pulse pressure

-Bradycardia -Hypotension -Urinary retention

Which assessment findings would the nurse expect to see in a client admitted to the hospital because of electrical burns? Select all that apply. One, some, or all responses may be correct. -Coughing -Burn odor -Smoky breath -Leathery skin -Cardiac arrest

-Burn odor -Leathery skin -Cardiac arrest

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? -Slow heart rate -Cool skin temperature -Bounding radial pulses -Increased urine output

-Cool skin temperature

Which nursing action has the highest priority prior to decannulating a patient who has had a tracheostomy for several months? -Deflate the tracheostomy tube cuff. -Undo the Velcro tracheostomy straps. -Place a replacement tube near the patient's bed. -Evaluate patient understanding of the procedure.

-Deflate the tracheostomy tube cuff.

Which actions will the nurse take as part of the ventilator bundle when caring for a patient with acute respiratory failure who requires mechanical ventilation? Select all that apply. -Elevate head of bed to 30-45 degrees. -Keep patient sedated for comfort. -Administer proton pump inhibitors. -Give injectable anticoagulant medications. -Assist with maintaining patient in prone position.

-Elevate head of bed to 30-45 degrees. -Administer proton pump inhibitors. -Give injectable anticoagulant medications.

A nurse is caring for a patient with a pulmonary embolism who is on warfarin therapy. Which parameter would the nurse monitor in this patient? -Hematomas -Polycythemia -B-type natriuretic peptide -White blood cell differentials

-Hematomas

Which examples will the nurse use to describe occupational hazards for burn injuries when teach a safety class on burns? Select all that apply. One, some, or all responses may be correct. -Tar -Power lines -Fertilizers -Radiators -Outdoor grills

-Tar -Power lines -Fertilizers

A client who sustained serious burns now has a stress ulcer. If complications occur, which clinical indicators of shock would the nurse immediately report to the primary health care provider? Select all that apply. One, some, or all responses may be correct. -Weakness -Diaphoresis -Tachycardia -Cold extremities -Flushed skin tone

-Weakness -Diaphoresis -Tachycardia -Cold extremities

A patient with chronic obstructive pulmonary disease is being considered for lung transplantation. The patient's medical history includes melanoma and hepatitis A, and the patient is not a current smoker. Which statement is true regarding transplantation eligibility? -The patient is eligible for lung transplantation. -Because of the history of smoking, the patient is not eligible. -Because of the history of hepatitis A, the patient is not eligible. -Because of the history of cancer, the patient is not eligible.

-The patient is eligible for lung transplantation.

The nurse is teaching a student nurse about pulmonary embolism. Which response by the student indicates to the nurse teaching was effective? -"A clot in the iliac vein may lead to a potentially lethal pulmonary emboli." -"A clot in the portal vein may lead to a potentially lethal pulmonary emboli." -"A clot in the jugular vein may lead to a potentially lethal pulmonary emboli." -"A clot in the lumbar vein may lead to a potentially lethal pulmonary emboli."

-"A clot in the iliac vein may lead to a potentially lethal pulmonary emboli."

Which instruction does the nurse give to a patient when removing the patient's chest tube? -"Lie on the side that is the opposite of the chest tube." -"Take some deep breaths throughout the procedure." -"Bear down while the tube is being removed." -"Drink a large amount of water just before the procedure."

-"Bear down while the tube is being removed."

Which statement regarding interventions for clients with inhalation burns shows a nurse needs further education? -"I would administer intravenous analgesia." -"I would prepare for an endotracheal intubation." -"I would anticipate the need for a fiberoptic bronchoscopy." -"I would immediately calculate the burned surface area with the rule of nines."

-"I would immediately calculate the burned surface area with the rule of nines."

The patient with small cell lung cancer experiences a sudden 5-pound weight gain without edema and a decreased urinary output. Serum sodium is 128 mEq/L. Which treatment would the nurse plan to teach the patient about? -Low-sodium diet -Head of bed elevated 30 degrees -1000 mL per day fluid restriction -Administration of desmopressin acetate nasal spray

-1000 mL per day fluid restriction

At which time would the nurse plan to administer morphine 2 mg by mouth every 2 hours as needed to a client who has burns on 55% of the body surface and requires dressing changes? -15 minutes before the dressing change -60 minutes before the dressing change -Along with a stool softener each time it is administered -Only if the client rates pain between 8 and 10 on the pain scale

-60 minutes before the dressing change

While assessing a patient with lung cancer, the nurse asks the patient, "Do you have persistent cough and fatigue?" Which functional health pattern is the nurse assessing? -Activity-exercise -Cognitive-perceptual -Nutritional-metabolic -Health perception-health management

-Activity-exercise

A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which initial physiological change will the nurse expect? -An increase in blood volume -An increase in serum potassium -A decrease in capillary permeability -A decrease in urinary specific gravity

-An increase in serum potassium

The nurse is planning care to prevent deformities and contractures in a client with burns. When would the nurse begin range-of-motion (ROM) exercises? -When pain has lessened -When vital signs are stable -When skin grafts are healed -When emotional status stabilizes

-When vital signs are stable

Which finding by the nurse is the best indicator that measures to improve oxygenation in a patient on mechanical ventilation for acute respiratory distress syndrome have been effective? -Oxygen saturation 90% to 93% -Decreased rhonchi and crackles -Patient report of improving dyspnea -Stable heart rate and BP

-Oxygen saturation 90% to 93%

A patient experiences a sucking chest wound as a result of a surgical thoracotomy. Which type of pneumothorax does the nurse suspect? -Tension -Iatrogenic -Traumatic -Spontaneous

-Traumatic

Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock? -Urine output 1000 mL in 8 hours -Oral temperature 101°F (38.3°C) -Client report of feeling very thirsty -Bounding radial and femoral pulses

-Client report of feeling very thirsty

Which early clinical manifestations of acute respiratory distress syndrome (ARDS) will the nurse monitor for when caring for a patient admitted with sepsis? Select all that apply. -Oliguria -Respiratory acidosis -Cough and restlessness -Dyspnea and tachypnea -Adventitious lung sounds

-Cough and restlessness -Dyspnea and tachypnea -Adventitious lung sounds

Which classification would the nurse use to describe burns that are painful, mottled red, weeping, and edematous? -Eschar -Full-thickness -Deep partial-thickness -Superficial partial-thickness

-Deep partial-thickness

The nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction? -Deep breathing -Hoarse quality to the voice -Pink-tinged, frothy sputum -Rapid abdominal breathing

-Hoarse quality to the voice

Which patient positioning strategies would the nurse use while caring for a patient with acute respiratory distress syndrome (ARDS)? Select all that apply. -Kinetic therapy -Prone positioning -Supine positioning -Trendelenburg position -Continuous lateral rotation therapy

-Kinetic therapy -Prone positioning -Continuous lateral rotation therapy

A client has a colon resection with an anastomosis. Which assessments by the nurse support a suspicion of impending shock? Select all that apply. One, some, or all responses may be correct. -Oliguria -Lethargy -Irritability -Hypotension -Slurred speech

-Oliguria -Irritability -Hypotension