final exam med surg II
A patient is admitted to the hospital with burns covering the anterior torso, anterior arms (bilateral), and anterior legs (bilateral). The nurse determines that the total body surface area (BSA) that is affected is:
45%
A client receives a polio vaccine during a clinic visit. The nurse explains that this will provide what type of immunity?
Active artificial immunity
Which of the following hormones retains sodium in the body?
Antidiuretic hormone
A nurse is implementing fluid resuscitation on a patient with full-thickness burns. Vital signs show a blood pressure of 85/55, pulse of 109, respiration rate of 22, and an hourly urine output of 15 ml. The nurse notifies the physician and expects which of the following interventions to be ordered?
Increase the IV fluid infusion rate.
A newly admitted patient has sustained deep partial-thickness burns to the face and trunk. Which of the following abnormal values can the nurse expect during the emergent phase?
Increased heart rate , Increased potassium level , Increased hematocrit levels , Decreased hemoglobin levels
A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply.
Cyanosis Shoulder pain Dyspnea Tachycardia Explanation: Hypotension, along with the other correct choices, is a manifestation of an air embolism.
The nurse is caring for a client with hypervolemia. Which of the following assessment findings are consistent with this condition? (Select all that apply)
Distended neck veins , Dyspnea , Crackles
The nurse is caring for a client in shock. The nurse should place the client in which position?
Flat, with legs elevated at a 20-degree angle
Smallpox is considered a biological agent of warfare. Which of the following are correct statements about the virus that will direct responses? Select all that apply.
It is extremely contagious after appearance of a rash A large amount of the virus is present in the saliva and pustules One form, variola major, has a 30% mortality rate Explanation: The incubation period for smallpox is 10 to 12 days. A flat, red-lesioned rash appears 2 to 3 days postexposure.
The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination?
It prevents secondary contamination to the health-care providers
The nurse is caring for a client who will need an oropharyngeal airway. How should the nurse determine the correct length?
Measure from the lip to the ear.
A patient is experiencing frequent runs of ventricular tachycardia. The nurse should obtain an order from the provider to check serum levels of:
Potassium and magnesium
A post operative patient has a decreased MAP of greater than 20mmHg from baseline value; elevated, thready pulse; decreased blood pressure; shallow respirations of 26/min; pale skin; moderate acidosis and moderate hyperkalemia. The nurse recognizes that this patient is in what phase of shock?
Progressive
A nurse is caring for a newly admitted patient following a burn injury. The nurse suspects an inhalation injury. Which of the following assessment findings would support the nurse's suspicion?
Singed nasal hair , Facial burns , Stridor
You are an Emergency Department nurse who has to care for three victims of anthrax. The first victim inhaled the toxin, the second victim ingested it, and the third victim suffered a skin infection. Which client should be cared for first?
The one who inhaled it
A nurse is monitoring the EKG of a patient in the ICU. The monitor shows a regular P to P interval with intermittent QRS waves that do have a regular interval when occurring, but are often missing. The EKG demonstrates no correlation between P waves and QRS waves. The nurse knows that this indicates which of the following heart rhythms?
Third degree AV block
The nurse is caring for a client with left-sided weakness from a stroke. When helping the client into a chair, what should the nurse do?
Use a transfer belt
A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for?
Ventricular dysrhythmias
The nurse knows that synchronization of cardioversion prevents the discharge from occurring during the vulnerable period of which of the following?
Ventricular repolarization Explanation: The synchronization of cardioversion prevents the discharge from occurring during the vulnerable period of repolarization (T wave), which could result in ventricular tachycardia (VT) or ventricular fibrillation. The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. The U wave represents repolarization of the Purkinje fibers.
Which term refers to the tendency for a chemical to become a vapor?
Volatility Explanation: The most common volatile agents are phosgene and cyanide. Persistence means that the chemical is less likely to vaporize and disperse. Toxicity is the potential of an agent to cause injury to the body. Latency is the time from absorption to the appearance of symptoms.
A patient is admitted to the hospital with 4th degree burns. The nurse expects the patient's wounds to be:
black/painless
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?
cidic Explanation: Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock?
decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Explanation: Shock may have different causes (e.g., hypovolemic, cardiogenic, septic) but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Option B could reflect dependent edema and sepsis. Option C reflects hypovolemia. Option D is reflective of anaphylactic or distributive shock.
Which of the following is a potential complication of amyotrophic lateral sclerosis?
respiratory failure
what is atropine used for?
reverse effects of bradycardia
The nurse is providing discharge instructions to a client with seizures. Which of the following statements regarding seizure triggers should be included?
"Alcohol and caffeine can trigger a seizure, so avoid them."
When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area?
1 Explanation: In clients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the client's palm, including the surface area of the digits, is approximately 1% of the total body surface area.
Which best describes the normal pulse pressure range?
30 to 40 mm Hg
The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury?
3422 Explanation: Convert pounds. to kilograms = 130/2.2 = 59 kg 2 mL x 59 kg x 58% TBSA = 6844 mL/24 hr. The infusion is regulated so that one-half of the calculated volume is administered in the first 8 hours after burn injury, so the nurse would infuse 3422 in the first eight hours and the second half of the calculated volume over the next 16 hours. Fluid resuscitation formulas are only a guideline. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response.
A 17-year-old who sustained a head injury in a motorcycle collision 2 days ago is responsive only to pain. Which intravenous (IV) fluid order would the nurse question because it could increase the risk of complications?
5% dextrose in water (D5W)
Which patients should be monitored closely for dehydration? Select all that apply.
A 50-year-old with an ileostomy , A 45-year-old with a temperature of 102.3°F , A 36-year-old taking diuretic therapy
Which of these clients should the nurse assess first?
A client with cellulitis, who is receiving a first dose of IV antibiotics and has throat tightness
The nurse is evaluating the serum laboratory results on the following four clients. Which laboratory result is a priority for the nurse to report?
A client with dehydration and a sodium level of 149 mEq/L
The nurse is caring for clients on a busy medical-surgical unit. Which client would be the priority to assess first?
A client with sepsis who is developing petechiae
A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What other conditions can cause this response in a healthy heart?
All options are correct. Explanation: There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart, including fever, shock, and strenuous exercise.
In a client with burns on the legs, which nursing intervention helps prevent contractures?
Applying knee splints Explanation: Applying knee splints is one method which can help prevent leg contractures by holding the joints in a position of function
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
Blood pressure and oxygen saturation
The lab calls to report an elevated serum osmolality of 350 mOsm/L. Which of the following factors increase the client's risk for this finding?
Elevated blood sugar
The nurse is caring for a client on the second postoperative day after coronary artery bypass (CABG) surgery. The client has a nursing diagnosis of: Impaired gas exchange. Which action would the nurse take to best assist the client with this diagnosis?
Ensure that the client uses the incentive spirometer every hour
A client is admitted with a three-day history of severe diarrhea. On assessment the client id hot, dry skin and a temperature of 100.6 F (38.1 C); pulse rate 110, bpm; and a blood pressureof90/50. Based on these findings, which of these nursing diagnoses should receive the highest priority?
Fluid volume deficit related to osmotic diuresis
Which rhythm is also termed a ventricular escape rhythm?
Idioventricular rhythm
The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?
Increase the force of myocardial contraction Explanation: The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction.
The nurse is learning about insensible water loss. Which of the following statements made by the nurse indicate that learning has occurred? (Select all that apply.)
It occurs through the skin, lungs, and stool. , It is seen in hypermetabolic states such as trauma, burns, fever, and thyroid crisis. , It increases due to evaporation of body water from the skin in a hot dry environment
A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?
Lund and Browder method Explanation: The Lund and Browder method divides the body into smaller segments. Different percentages are assigned to body parts, depending on patient's age. For example, the adult head is equivalent to 9%,whereas the infant head is 19%. This method is more accurate when dealing with children. The rule of nines and hand method are quick assessment techniques for estimating burns. The Parkland formula incorporates fluid resuscitation requirements for burns.
A client with heart failure is complaining of nausea. The client has received IV furosemide, and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol, digoxin, furosemide, and multivitamins. Which of the following are the appropriate nursing actions to take before administering the digoxin? (Select all that apply)
Notify the health care provider , Report indications of nausea , Assess for visual changes
The client is diagnosed with cataracts. Which symptom would the nurse expect the client to report?
Painless, blurry vision
A charge nurse observes a new nursing graduate perform an ear irrigation to remove impacted cerumen from a client's ear. The charge nurse intervenes during the procedure if the new nursing graduate does which of the following?
Positions the client with the affected side up following the irrigation
Which electrolyte is a major cation in body fluid?
Potassium Explanation: Potassium is a major cation that affects cardiac muscle functioning. Chloride, bicarbonate, and phosphate are anions.
Morphine sulfate has which of the following effects on the body?
Reduces preload
The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia?
hypovolemia Explanation: The causes of sinus tachycardia include physiologic or psychological stress (acute blood loss, anemia, shock, hypovolemia, fever, and exercise). Vagal stimulation, hypothyroidism, and digoxin will cause a sinus bradycardia.
The nurse is providing dietary instructions to a client with hyponatremia. Which statement made by the client indicates a need for further instruction?
i will increase my water intake
What is the major clinical use of dobutamine?
increase cardiac output. Explanation: Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery.
Clients diagnosed with hypercalcemia should be monitored for which of the following complications?
kidney stones
A preceptor informs a nursing student that a client has a potassium level of 2.4. Which of the following findings would the nurse expect to observe?
muscle cramps
Which patient is most at risk for fluid volume overload?
The 35-year-old with kidney failure
The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer?
0.45% sodium chloride Explanation: Half-strength saline (0.45% sodium chloride) solution is frequently used as an IV hypotonic solution.
A client 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 client?
100% oxygen via a tight-fitting, nonrebreather face mask
The nurse is admitting a client diagnosed with Guillain-Barre syndrome (GBS). Which question should the nurse ask the client?
"Have you had a viral illness in the last few weeks?"
The nurse provides discharge teaching to a client who had a total hip replacement 4 days ago. Which client statement indicates that additional teaching is necessary?
"I will concentrate on leaning forward as I carefully sit down in a chair."
A nurse is teaching the client about the causes of fast heart rates. What client statement indicates the client requires more teaching?
"I will drink coffee with only two of my meals." Explanation: Stimulation of the sympathetic nervous system with caffeinated beverages, smoking, and drinking alcohol increases heart rate. The client is still drinking caffeine with two meals, increasing the risk for a fast heart rate. Taking medications such as metoprolol and levothyroxine will help the client maintain a normal heart rate by decreasing stimulation of the sympathetic nervous system.
The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction?
"I will not salt my food; instead I'll use salt substitute." Explanation: The client should avoid salt substitutes. The nurse must caution clients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey.
Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." Explanation: The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers.
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?
BUN: 28 mg/dL Explanation: The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated.
The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?
Bicarbonate Explanation: Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.
The nurse and student nurse are observing a cardioversion procedure. The nurse is correct to tell the student that electrical current will be initiated at which time?
During ventricular depolarization Explanation: The electrical current is initiated at the R wave when ventricular depolarization occurs. The electrical current completely depolarizes the entire myocardium with the goal of restoring the normal pacemaker of the heart.
The nurse is caring for a client with a blast injury. Which of the following assessment findings is consistent with a blast lung? (Select all that apply)
Dyspnea , Cough , Chest pain
The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse?
Electrical burns usually follow an internal path. Explanation: Electrical current follows the path of less resistance. Because the skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current.
The nurse is caring for a client with a suspected spinal cord injury. The nurse should keep the client in which of the following positions?
Extended, flat position
The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation?
Mean arterial pressure of 70 mm Hg Explanation: The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.
The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in?
Priority 1 Explanation: Triage category "Immediate" is priority 1 (red) and includes injuries that are life threatening but survivable with minimal intervention, such as sucking chest wound, airway obstruction secondary to mechanical cause, and shock.
The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in?
Progressive Explanation: In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline
Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as
Sodium nitroprusside Explanation: Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume.
A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi?
Warfarin Explanation: Because atrial function may be impaired for several weeks after cardioversion, warfarin is indicated for at least 4 weeks after the procedure. Patients may be given amiodarone, flecainide, ibutilide, propafenone, or sotalol prior to cardioversion to enhance the success of cardioversion and prevent relapse of the atrial fibrillation
The nurse cares for a client following the insertion of a permanent pacemaker. What discharge instruction(s) should the nurse review with the client? Select all that apply.
Wear a medical alert, noting the presence of a pacemaker Check pulse daily, reporting sudden slowing or increase Avoid handheld screening devices in airports
A community health nurse is assisting residents involved in a hurricane and flood. Many of the residents are emotionally despondent and refuse to evacuate their homes. With regard to rescue and relocation of the residents the nurse plans to first:
attend to nutrition and basic needs
A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse?
bicarbonate-carbonic acid buffer system Explanation: The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system. The renin-angiotensin-aldosterone system regulates blood pressure. The sodium-potassium pump regulate homeostasis. The ADH-ANP buffer system regulates water balance in the body.
The nurse is caring for a client in the emergency department who has accidently ingested an unknown caustic substance. Which of the following actions is most appropriate for the nurse to take?
contact poison control
A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?
neurogenic shock Explanation: Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Septic shock is a subcategory of distributive shock, but it is associated with overwhelming bacterial infections.
The nurse analyzes a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm a
normal sinus rhythm. Explanation: The electrocardiogram (ECG) tracing shows normal sinus rhythm (NSR). NSR has the following characteristics: ventricular and atrial rate: 60 to 100 beats per minute (bpm) in the adult; ventricular and atrial rhythm: regular; and QRS shape and duration: usually normal, but may be regularly abnormal; P wave: normal and consistent shape, always in front of the QRS; PR interval: consistent interval between 0.12 and 0.20 seconds and P:QRS ratio: 1:1.
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply.
pH PaCO2 HCO3 Explanation: Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate (HCO3). The two types of acid-base imbalances are acidosis and alkalosis.
A client with respiratory acidosis is admitted to the intensive care unit for close observation. What client complication associated with respiratory acidosis would the nurse observe?
papilledema Explanation: If respiratory acidosis is severe, intracranial pressure may rise, causing papilledema. Stroke and hyperglycemia are not associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.
A client is diagnosed with a dysrhythmia at a rate slower than 60 beats/minute with a regular interval between 0.12 and 0.20 seconds. What type of dysrhythmia does the client have?
sinus bradycardia Explanation: Sinus bradycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a slower than usual (less than 60 beats/minute) rate.
Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock?
Neurogenic Explanation: The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.
The nurse is assessing a client with burns to the left arm. Which of the following assessment findings suggest the development of compartment syndrome? (Select all that apply)
Decreased radial pulse strength , Capillary refill greater than 3 seconds , Decreased sensation
The nurse knows that what PR interval presents a first-degree heart block?
0.24 seconds Explanation: In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds would indicate a first-degree heart block.
Which of the following IV solutions is hypotonic?
0.45% saline
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
36% Explanation: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area.
An explosion occurred at a nearby factory at 1800 hours. An emergency department charge nurse receives a call from the emergency management systems (EMS) personnel, stating that 35 clients will be transported to the hospital within 10 minutes by ambulance. Upon arrival, these clients are triaged at the scene as red and yellow, according to the NATO mass casualty categories. More clients will be coming, and the unit is already short-staffed. Which action should the charge nurse initiate first?
Activate the hospital's emergency response plan.
The nurse is working on a telemetry unit, caring for a client who develops dizziness and a second-degree heart block, Mobitz Type 1. What will be the initial nursing intervention?
Administer an IV bolus of atropine. Explanation: Atropine 0.5 mg given rapidly as an intravenous bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic second-degree heart block.
A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take?
Ask the client if he ever sustained a bee sting in the past
A nurse working in an emergency department receives a call that an unknown number of clients have been exposed to a nerve agent during a terrorist attack on a government center. Which medication should the nurse prepare to have readily available in sufficient quantities to treat the clients?
Atropine sulfate
In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart?
Nitroprusside Explanation: A disadvantage of nitroprusside (Nipride) is that it causes hypotension.
The nurse is assessing a patient with a probable diagnosis of first-degree AV block. The nurse is aware that this dysrhythmia is evident on an ECG strip by what indication?
Delayed conduction, producing a prolonged PR interval Explanation: First-degree AV block may occur without an underlying pathophysiology, or it can result from medications or conditions that increase parasympathetic tone. It occurs when atrial conduction is delayed through the AV node, resulting in a prolonged PR interval.
The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L) and a fluid volume excess. The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving?
Discontinue the intravenous lactated Ringer solution. Explanation: The lactated Ringer intravenous (IV) fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer solution contains more sodium than daily requirements, and excess sodium worsens fluid volume excess. Lactated Ringer solution also contains potassium, which would worsen the hyperkalemia.
An older-adult nursing home resident who has always been alert and oriented is now showing signs of dehydration and has become confused. Which electrolyte imbalance is most likely involved?
Hyponatremia
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?
Metabolic alkalosis Explanation: A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.
Which of the following assessments should be included in the plan of care for a client who is at risk for developing hypocalcemia?
Monitor magnesium levels.
Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?
Natural Explanation: Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.
An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?
The client has experienced extensive full-thickness burns. Explanation: In full-thickness burns, nerves are damaged and consequently painless.
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.
A client with hypervolemia asks the nurse by what mechanism the sodium-potassium pump will move the excess body fluid. What is the nurse's best answer?
active transport Explanation: Active transport is the physiologic pump maintained by the cell membrane that results in the movement of fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate (ATP) for energy. The sodium-potassium pump actively moves sodium against the concentration gradient out of the cell, and fluid follows. Passive osmosis does not require energy for transport. Free flow is the natural transport of water. Passive elimination is a filter process carried out in the kidneys.
An older adult patient presents to the emergency department reporting severe vomiting and diarrhea, sweating, and rapid heartbeat but has a normal temperature. In continuing the assessment of the patient, what should the nurse first suspect?
dehydration
A client with a head injury has increased intracranial pressure. Which is the priority for the nurse to assess?
heart rate
A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as
18%. Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the total body surface area (TBSA), quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). In this case the client's abdomen (9%) and front of the left leg (9%) add up to 18%.
A nurse is caring for a patient with burns covering 45% of their total body surface area (TBSA). The nurse initiates fluid resuscitation and will continue resuscitation for:
24 hrs
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?
5% albumin Explanation: Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared to crystalloid solutions.
A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits
Adventitious breath sounds Explanation: The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds
The nursing student asks the nurse to describe the difference between sinus rhythm and sinus bradycardia on the electrocardiogram strip. What is the nurse's best reply?
The only difference is the heart rate." Explanation: All characteristics of sinus bradycardia are the same as those of normal sinus rhythm except for the rate, which will be below 60 in sinus bradycardia. The P waves will be shaped differently in other dysrhythmias. The QRS is the same voltage for sinus rhythms. The P-R interval is prolonged in atrioventricular blocks.
The client asks the nurse to explain what is meant by a ventricular bigeminy cardiac rhythm. What is the best response by the nurse?
The rhythm has a normal beat, then a premature beat pattern." Explanation: Bigeminy is a rhythm in which every other complex is a premature ventricular contraction (PVC). In trigeminy, every third complex is a PVC. The rhythm is not regular and the rate should not be 150-250 bpm.
The nurse documents that a client is having a normal sinus rhythm. What characteristics of this rhythm has the nurse assessed?
The sinoatrial (SA) node initiates the impulse. Explanation: The characteristics of normal sinus rhythm are heart rate between 60 and 100 beats per minute; the SA node initiates the impulse; the impulse travels to the AV node in 0.12 to 0.2 seconds; the ventricles depolarize in 0.12 seconds or less; and each impulse occurs regularly.
When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?
aorta
