Exam2

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching?

"my spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

Rate

# of breaths per minute

Want a RASS score of what?

0 through -2

Troponin

0-0.03

A patient arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the patient?

100% oxygen via a tight-fitting, nonrebreather face mask

A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report?

36

Tidal volume

Amount of air delivered with each breath

FiO2

Amount of oxygen required to maintain saturation

Omalizumab side effect

Anaphylaxis

Salmetrol side effects

Anxiety, thrush, sores in mouth

Albuterol side effects

Bradycardia and hypotension

Precedex side effect

Bradycardia, hypotension

Tamponade treatment

Pericardiocentesis - remove fluid to take pressure off heart, guided by echo

DOPE

Dislodgement, Obstruction, Pneumothorax, Equipment

Ipratropium side effect

Dry mouth, systemic overdose: blurred vision, headache, palpitations, tremors

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

increased respiratory rate

Pericarditis CRP

Greater than 3.0

Acute respiratory failure - PaCO2

Higher than 50

PIP

Highest level of pressure applied in the lung during inhalation

Propofol side effects

Hypotension, infusion syndrome: break down muscles and myoglobin damages kidneys, metabolic acidosis

Endocarditis most seen in:

IV drug users

Solumedrol side effect

Increase blood sugar, increase insulin, avoid crowds

Endocarditis

Inflammation of the inner lining of the heart and valves

Becks triad

Jugular Venous distension, muffled heart sounds, hypotension

Acute respiratory failure - PaO2

Less than 60

Acute respiratory failure - SaO2

Less than 90%

Pericarditis s/s

Pericardial friction rub, increased WBC, EKG ST elevation and a-fib

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?

Plasma proteins moving out of the intravascular compartment

PEEP

Positive pressure added at end of expiration to prevent alveoli from completely emptying

Montelukast

Prevention

Omalizumab

Prevention

Versed side effects

Slow awaking due to storing in adipose tissue

Bydesonide and fluticasone side effect

Thrush, lesions, drainage

Endocarditis s/s

Vegetation, splinter hemorrhage, oslers noses, janeway lesions

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?

a rise in blood pressure

A patient is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for the patient? Select All That Apply.

assess for airway patency, administer oxygen as prescribed, elevate extremities if no fractures are present.

During a first aid class, a student asks what should be done if a person's clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to perform this action. Which action did the nurse describe?

assess the person's breathing

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?

crackles

A client receives a scalding burn to the chest and arms. The nurse assesses that the burned areas are painful, red to white, and edematous. How will the nurse classify these burns?

deep partial-thickness burns

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

diminished breath sounds

Which type of burn/injury may cause a client to have a cervical spine injury?

electronic burns

The nurse is caring for a patient who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which findings does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

elevated hematocrit levels

A patient is undergoing fluid replacement after being burned 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 bpm, and a urine output of 20 ml over the past hour. The nurse reports the findings to the health care provider and anticipates which prescription?

increasing the amount of intravenous Lactated Ringer's solution administered per hour.

The nurse should identify which newborn to be at significant risk for hypothermic alteration in thermoregulation?

low birth weight

A client with a history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?

metformin

While obtaining the vital signs of a client, the nurse finds that the body temperature of the client is 98.6 F. The nurse concludes that the client is experiencing what?

normothermia

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/minute, and a productive cough with blood-tinged sputum. Which action should the nurse take next?

Place the client in an upright position

The disaster management team is caring for workers of a factory who survived a thermal blast. Which findings in the workers would the nurse consider as confirmation of second degree burns?

Presence of moist blebs and skin appears mottled white or pink

Salmeterol

Prevention

budesonide and fluticasone

Prevention

Cardiac tamponade s/s

Pulses paradoxes, becks triad

Albuterol

Rescue

Ipratropium

Rescue

Soul-medrol

Rescue

Pericarditis

Sac around the heart

The nurse is caring for a patient who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the patient?

flushing

The 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

A client with a chest injury has suffered flail chest. The nurse assess the client for which most distinctive sign of flail chest?

paradoxical chest movement

What is the most appropriate measure for a nurse to use when assessing core body temperature when there are suspected problems with thermoregulation?

rectal thermometer

The nurse is preparing to care for a burn patient scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which findings is the anticipated therapeutic outcome of the escharotomy?

return of distal pulses

A nurse is administering a histamine H 2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent?

stress ulcer

A nurse who is assessing intake and output for a client with severe burns notes that the patients intake is 2,000 mL greater than output. Which rationales should the nurse associate with this discrepancy? Select All That Apply.

the patient is experiencing vasoconstriction, the patient is experiencing increased insensible output, the patient is experiencing third spacing.

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what?

urinary output

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

warming the newborn