EXAM 2 MDC 4
EMBOLISM The nurse is caring for a group of clients. Which client is at most risk for a pulmonary embolism?
-A long distance truck driver
PROVIDER A nurse is assessing a client who sustained superficial partial thickness and deep partial thickness burns 38 hours ago. Which finding should the nurse report to the provider
-ABG pH 7.31, PaCO2 37 mm Hg, HCO3 31 mEq/L
ARDS A nurse is caring for a client who suffered third degree burns to both his hands after a house fire. He presented with an airway injury secondary to smoke inhalation. The client is currently on ventricular with 100% [?]O2. Based on this information, which of the following would be a sign or symptom of acute respiratory distress syndrome (ARDS)?
-ABG results show PaO2 50 mmHg
FOLLOWING A client is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse is which of the following
-Administer oxygen
EXPECT A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect
-Albumin 2.9 g/dL
PROVIDER When caring for a client who has early sepsis, which change in status is most important for the nurse to report to the health care provider
-Altered mental status
SHOCK A client with [?] trauma and possible spinal cord injury is admitted to the emergency department. Which finding by the nurse will help confirm a diagnosis of neurogenic shock
-Apical pulse of 48 beats/minute
PNEUMOTHORAX Which of the following interventions is not appropriate for a client diagnosed with a pneumothorax
-Apply wet to dry dressing to wound
TAKE A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take
-Assess breaths sounds every 4 hours
CLIENT The nurse is caring for a client experiencing hypovolemic shock. Which of the following interventions would not be appropriate for this client
-Assist to sitting position
Intensive care unit nurse is caring for a client. The ventilator alarms are sounding. Which interventions should the nurse implement first
-Auscultate the client's lungs sounds
EXPECT A nurse is caring for a client who is in the progressive state of shock. Which finding should the nurse expect?
-Blood pressure change from 129/78 mm/Hg to [89]/45 mmHg
FIRST A nurse is caring for a client with arterial blood gas results pH 7.21, PaCO2 60 mmHg, PaO2 42 mmHg, HCO3 22. Which medication should the nurse prepare to administer first
-Bronchodilators
FOLLOWING A client is admitted to the emergency department with a full thickness burn to the right arms. Upon assessment, the arm is edematous, fingers are molted, and radial pulse is absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should perform which of the following
-Call the healthcare provider to report the loss of radial pulse
CHARACTERISTICS When assessing a client who has suffered a burn injury, the nurse classifies the burn as a full thickness burn based on observing which characteristics
-Charred skin with milky areas
CLIENT A client who has an endotracheal tube is being considered for a tracheostomy. Which of the following criteria would suggest the placement of a tracheostomy in this client
-Client is unable to maintain airway when extubated
PROVIDER During change of shift report, a nurse learns a client has been admitted with dehydration and hypertension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider
-New onset of confusion and agitation
MINUTES Nurse is managing several IV medications to maintain the blood pressure of a client in hypovolemic shock. Which medication places the client at risk for hypertensive reaction, requiring the nurse to assess the blood pressure at least every 15 minutes
-Norepinephrine OR Sodium nitroprusside
FIRST Who is 1-day post-operative following chest surgery, is having difficulty breathing, has bilateral rales, and is confused and restless? Which intervention should the nurse Implement first
-Notify the rapid response team
EFFECTIVE Which assessment is important for the nurse to evaluate whether the treatment of the client with anaphylactic shock has been effective
-Oxygen saturation
FINDING Nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?
-Pain, especially with inspiration
CHEST A client with a chest injury has suffered a flail chest. The nurse assesses the chest for what most descriptive sign of flail chest?
-Paradoxical chest movement
IMPLEMENT A client in respiratory failure is diagnosed with flail chest. After the client is intubated, which treatment does the nurse expect to implement
-Positive end expiratory pressure (PEEP)
FIRST A nurse is assisting the provider in caring for a client who has developed a tension pneumothorax. Which actions should be performed first?
-Prepare for large bore needle thoracostomy
DIC A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which statement indicates the nurses correct understanding of DIC
-"DIC is caused by abnormal coagulation involving fibrinogens"
FAMILY A client presented to the ED after receiving second and third degree burns from a kitchen grease spill. The tops of both thighs, the groin area and the lower abdomen were the areas of injury. About three hours after the injury, the client begins to decompensate and is being prepped for intubation. Regarding the changes in client status, which explanation by the nurse is correct when educating the client's family?
-"Even a burn as little as 25% of the body can cause a systemic response, requiring emergency management."
APPROPRIATE A nurse in a burn [?] center is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which nursing statement is appropriate
-"Large, surgical incisions will be made to the hardened dermal layer to improve circulation"
TRANSFUSION Nurse is caring for a client who is in hypovolemic shock related to hemorrhage. The nurse prepares IV tubing to infuse with which IV solution in preparation for a blood transfusion
-0.9% sodium chloride
ML/HR You receive an order for dopamine 20 mcg/Kg/minute. The bag is labeled dopamine 100 mg/50 mL. The client weighs 88 pounds. What is the infusion rate as mL/hr
-24 mL/hr
AS A burns client is brought into the emergency department with the following burns: half of the [front torso], entire left arm, front of left leg. The nurse should record the total body surface area burns as
-27%
FIRST A nurse is assessing four clients. Which of the following clients should the nurse assess first?
-A client that has self-extubated his endotracheal tube
SYNDROME A nurse is reviewing the health records of clients. Which client is at greatest risk for developing acute respiratory distress syndrome and multiple organ dysfunction syndrome
-A client who experienced anaphylactic shock
SYNDROME A nurse is reviewing the health records of clients. Which client is at least risk for developing acute respiratory distress syndrome?
-A client who has a hemoglobin of 10.1 mg/dL post 1 unit PRBC
MODS A nurse is reviewing the health records of clients. Which client is at greatest risk for developing acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS)?
-A client who is experiencing septic shock
SHOCK A nurse is educating a new nurse on the different types of shock. The new nurse is asked to identify which client is not experiencing distributive shock
-A client with a tension pneumothorax and cardiovascular compression
FIRST After receiving report of four clients, the nurse determines the order of the clients. Based on report, the nurse will prioritize the clients to see which one first
-A healthy 18-year-old with rapid shallow respirations
INCLUDE A nurse is planning care for a client who has severe acute respiratory distress syndrome (ARDS). Which actions should the nurse include
-Conservative fluid therapy and diuretics -Assess lungs hourly and suction to maintain airway -Maintain intubation and mechanical ventilator support -Consider [d...] and enteral nutrition and/or parenteral nutrition
ORDERED A client has been diagnosed with pulmonary embolism. What diagnostics and treatments does the nurse anticipate will be ordered?
-D-Dimer -Thrombolytics -CT angiogram
SHOCK When the charge nurse is evaluating the skills of the new RN, which action by the new RN indicates a need for more education in the care of clients with shock
-Decreasing room temperature to 60 degrees Fahrenheit for a client with neurogenic shock
CLIENT The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate pneumothorax in this client
-Diminished breath sounds
CONDITION Nurse is caring for a client treated with mechanical ventilation. The ventilator sounds a low-pressure alarm. The nurse immediately assesses for other signs of which condition
-Disconnected endotracheal tube
FOR An older adult client arrives in the emergency department after falling off the roof. The nurse observes "sinking inward" of the loose chest area during inhalation and "puffing out" of the same area during exhalation. Arterial blood gas results show severe hypo... and hyper.... Which procedure does the nurse prepare for
-Endotracheal intubation
CLIENT The nurse is caring for a ventilated client. Which intervention is appropriate for this client?
-Ensure there is a manual resuscitation bag at the bedside
POSITIONED A client who was admitted after receiving a blow to the head begins to show signs of shock. How should the client be positioned?
-Flat with legs elevated
QUESTION A client with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 beats/min, and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health provider will the nurse question?
-Give furosemide
EXPECT A nurse is assessing a client who has fluid volume overload from cardiogenic shock. Which manifestation of cardiogenic shock should the nurse expect
-Heart rate 121 beats/minute
TEACHING A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching
-I will be on a special shower table to enhance wound inspection and debridement
FIRST The client who is 2 days postoperative following a pneumonectomy, has an apical pulse rate of 128 beats per minute and a blood pressure of 80/50 mmHg. Which intervention should the nurse implement first
-Increase the client's IV rate as ordered
MAP A client is being treated for distributive shock with IV vasopressors. The nurse expects the drugs to have which effect on the client's MAP?
-Increased MAP (can't read the rest, but it's the longer one)
PRESSURE A client is being treated for distributive shock with IV norepinephrine. The nurse expects the drug to have which effect on the client's mean arterial pressure?
-Increased MAP with no change in vascular volume
ANTICIPATE A nurse is caring for a client in the nonprogressive compensatory stage of hypovolemic shock. Which finding should the nurse anticipate
-Increased thirst reflex and moderate vasoconstriction
INTERVENTIONS A client with a pulmonary embolism may have which of the following interventions?
-Inferior vena cava (IVC) filter -Embolectomy -Heparin drug therapy
QUESTION A client with shock of unknown etiology whose hemodynamic monitoring indicates a blood pressure 93/54 mmHg, pulse 64 beats/minute, and an elevated pulmonary arterial wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question
-Infuse normal saline at 250 mL/hr
FOLLOWING A nurse is caring for a client who has sustained burns over [37%] total body area. The client's voice has become hoarse, a heavy cough has developed, and the client is drooling. The nurse should identify these findings as indication that the client has which of the following?
-Inhalation injury
REPORTED A client is receiving warfarin after pulmonary embolism. The nurse evaluates the lab results and notifies the physician the client's level is therapeutic when which of the following numbers is reported
-International normalized ratio (INR) 2.0
VAPS Which actions are essential for the nurse caring for a mechanically ventilated client to prevent ventilator acquired pneumonia (VAPS)?
-Keep the head of the bead elevated at least 30 degrees -Prevent aspiration -Turn and reposition the client every two hours -Prevent pressure ulcers around the mouth
CARE A nurse is planning care for an adult client who [endured] severe burn injuries. Which interventions should the nurse include in the plan of care
-Limit visitors in the client's room when immunosuppressed -Offer high calorie, high protein foods or supplement feeding -Ambulate two or three times a day and progress in length each time
SHOCK Which intervention will the nurse include in the plan of care for a client who has cardiogenic shock?
-Monitor breath sounds frequently
COMPLICATION A client in the Intensive Care Unit (ICU) was recovering from moderate burned and smoke inhalation. His condition was improving and plans were made to transfer him to a step-down unit. On the morning of the transfer, the client began to experience elevated temperature, and shortness of breath. Urine output decreased to 10 milliliters per hour. Labs were drawn and indicated elevated WBC, GFR, creatinine, and liver enzymes. This client is experiencing which medical complication
-Multiple organ dysfunction syndrome (MODS)
TAKE A client with neurogenic shock just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which if the following actions should the nurse take
-Prepare to administer atropine IV -Obtain baseline body temperature -Prepare for intubation and mechanical ventilation
CLIENT A postoperative client reports a sudden onset of shortness of breath and pleuritic chest pain. Assessment findings include diaphoresis, hypotension, crackles in the left lobe, and pulse oximetry of 80% on room air. What does the nurse suspect has occurred in this client
-Pulmonary embolism
CONDITION A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high pressure alarms on the ventilator sounds and notes the client has an absent breath sound in the right upper lobe of the lungs. The nurse immediately assesses for other signs of which condition
-Right pneumothorax
CLIENT The nurse is developing a care plan for a client in the acute phase of a burn injury. Which of the following would be a priority nursing diagnosis for this client
-Risk for infection related to slow healing graft donor site
IN A client presents with the following vital signs: BP 90/60 mmHg, temperature 38.3*C (101*F), heart rate 116 beats/minute, respiratory rate 24 breaths/minute. The client has a post-op abdominal incision that is warm and red. What type of shock is the client in
-Septic shock
EFFECTIVE A client is being treated for hypovolemic shock. As the nurse reassesses the client, which finding indicates the interventions are effective
-Serum lactate and serum potassium level are declining
EXPECT Nurse is evaluating the lab values of a client who is in the resuscitation phase following a major burn. Which of the following lab findings should the nurse expect
-Sodium 143
INJURY A certified burns nurse is introducing a new nurse to the burn's unit. The nurse is educating the new nurse on the degree stages of burns. Which of the following provides the correct description of a wound to the correct level of injury
-Superficial thickness reddened skin, desquamation heals quickly without intervention
CREAM A client has been prescribed silver [?} for a burn injury. Which of the following findings would give the nurse reason to question the order for this topical burn cream
-The client has a sulfa allergy listed in the chart
ASSESSED A nurse is caring for a client in shock. The nurse understands the client's sympathetic nervous system (SNS) is still correctly attempting to compensate when the following is assessed
-The client has decreased peripheral pulses -The client has an increased thirst -The client has an increasing respiratory rate -The client has widening pulse pressure?
PROVIDER Which information about a client receiving vasopressin (dobutamine) to treat septic shock is most important for the nurse to communicate to the health care provider
-The client is complaining of chest pain
INTERVENTION The client with neurogenic shock is receiving a phenylephrine infusion through a left forearm IV. Which assessment information obtained by the nurse indicates need for immediate intervention
-The client's IV infusion site is cold and pale.
successful Which of these findings is the best indicator that the fluid resuscitation for a client with hypovolemic shock has been successful?
-Urine output is 60 mL over the last hour
RESUSCITATION A nurse is assessing the fluid statues of a chest being treated for a burn during the emergent phase. Which of the following is an indicator of adequate fluid resuscitation
-Urine output of at least 30mL
FOLLOWING When assessing a client who is severely bleeding and at risk for hypovolemic shock, the nurse anticipates which of the following?
-Weak, thready pulse
FOLLOWING The [pathophysiology of acute respiratory distress syndrome is characterized by which of the following?
-[refractory hypomania]
RESUSCIATION A client with 55% body surface burns arrives in the ED. The client weighs 160 pounds. Using the Parkland Burn Formula, calculate the hourly flow rate of lactated ringers during the first 8 hours of fluid resuscitation.
1000
MAP Calculate the mean arterial pressure (MAP) in mmHg for a client with blood pressure of 84/46. Record as whole number.
59
next A client arrived at the burn unit more than two weeks ago. The care plan for this client requires assistance by the nurse to perform range of motion (ROM) exercises and help with mobility. The client tells the nurse he is no longer going to participate due to the pain it always causes. Which of the following should the nurse do next
Acknowledge the client's concerns regarding pain and discuss how to promote his exercise plan in a way to have less pain but allow therapeutic level of treatment
EXPECT The nurse recognizes indications of respiratory distress include all of the following except?
Stupor
