Med surge final REVIEW QUESTIONS

Lypase

0-160

AST

0-35

Bilirubin

0.3-1

Creatine

0.6-1.2

Regular INR

0.8-1.1

The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? 1. The client with renal vein thrombosis who has a heparin drip infusion and a PTT of 92. 2.The client on peritoneal dialysis who has a clear dialysate draining from the abdomen. 3. The client on hemodialysis whose right upper arm fistula has an audible bruit. 4. The client diagnosed with cystitis who is complaining of burning on urination

1. The therapeutic PTT level should be 1.5 to 2 times the normal PTT of 39 seconds. The therapeutic levels of heparin are 58 and 78. With a PTT of 92, the client is at risk for bleeding, and the heparin drip should be held. The nurse should assess this client first.

The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints. 2.The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale. 3. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally. 4. The client who has been turning on the call light frequently and stating her care has been neglected

1. This client may or may not be stable. The client may have "no complaints" at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first

Which client should the charge nurse assess first after receiving the change-of-shift report? 1. The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute. 2. The client with an L-4 SCI who is frightened about being transferred to the rehabilitation unit. 3. The client with an L-2 SCI who is complaining of a headache and feeling very hot all of a sudden. 4. The client with a C-4 SCI who is on a ventilator and has a pulse oximeter reading of 98%

1. This client with dyspnea and a respiration rate of 12 has signs/symptoms of a respiratory complication and should be assessed first because scending paralysis at the C-6 level could cause the client to stop breathing

Magensium (Mg)

1.5-2.5

ICP device level

10-15/ LESS THEN 10 normal

Bun

10-20

PT

11-13.5

hemoglobin

12-17.5

Sodium (NA)

135-145

Your patient burned his left arm and face, weights 50Kg, how much IVF do we give patient in last 16 hours?

1800ml

The ED nurse is triaging patients following a multi-vehicle accident who is going to be seen in order: 1. Patient with leg pain and arm closed fracture 2. Patient with paradoxical chest wall movement and respiratory distress. 3. Patient with open fracture of left femur 4. Patient with facial lacerations and neck tenderness.

2, 3, 4, 1

Warfrin INR

2-3

Your patient burned his face, thorax, genetalia, right arm and right leg, weighs 100Kg, how much IVF does he receive total in 24 hours?

22000ml

Phosphorus (P)

3-4.5

Potassium (K)

3-5.0

The client in the post-anesthesia care unit (PACU) has noisy and irregular respirations with a pulse oximeter reading of 89%. Which intervention should the PACU nurse implement first? 1. Increase the client's oxygen rate via nasal cannula. 2. Notify the respiratory therapist to draw arterial blood gases. 3. Tilt the head back and push forward on the angle of the lower jaw. 4. Obtain an intubation tray and prepare for emergency intubation

3. The client is exhibiting signs/symptoms of hypopharyngeal obstruction, and this maneuver pulls the tongue forward and opens the air passage

Albumin

3.5-5

Regular Urine output

30 Ml/hr

CKMB

30-170

Amylase

30-220

Hemocrit

36-50

The unlicensed assistive personnel (UAP) tells the nurse the client has a blood pressure of 78/46 and a pulse of 116 using a vital signs machine. Which intervention should the nurse implement first? 1. Notify the healthcare provider immediately. 2. Have the UAP recheck the client's vital signs manually. 3. Place the client in Trendelenburg position. 4. Assess the client's cardiovascular status

4, The nurse should immediately go to the client's room to assess the client

ALT

4-36

PTT

40-60

Ejection Fracture

50-75 MUST HAVE 10-15 to be considered for Heart Transplant

Heparin PTT

60-80

Your patient has both legs burned and weighs 100Kg, how much IVF would we give him in first 8 hours?

7200ml

In estimating BSA of a burn, each upper extremity in an adult represents what percentage of the total body area?

9%

Calcium (Ca)

9-10.5

chloride (Cl)

98-106

Emergency medical technicians arrive at the emergency department with an unresponsive patient who has an oxygen mask in place. Which action would the nurse take first? A. Assess that the patient is breathing adequately. b. Insert a large-bore intravenous line. c. Place the patient on a cardiac monitor. d. Assess for the best neurologic response.

A A. Assess that the patient is breathing adequately. b. Insert a large-bore intravenous line. c. Place the patient on a cardiac monitor. d. Assess for the best neurologic response.

An emergency room nurse assesses a patient who was rescued from a home fire. The patient suddenly develops a loud, brassy cough. What action would the nurse take first? a.Apply oxygen and continuous pulse oximetry. b.Provide small quantities of ice chips and sips of water. c.Request a prescription for an antitussive medication. d.Ask the respiratory therapist to provide humidified air.

A ´Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the patient oxygen. Patients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

The nurse is caring for five patients on the medical-surgical unit. Which patients would the nurse consider to be at risk for postrenal acute kidney injury (AKI)? (Select all that apply.) A Man with prostate cancer b. Woman with blood clots in the urinary tract c. Patient with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

A,B,C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes postrenal AKI. Severe burns would be a prerenal cause. Lupus would be an intrarenal cause for AKI.

A nurse assesses a patient who is experiencing an acid-base imbalance. The patient's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3- 18 mEq/L (18 mmol/L). For which clinical manifestations would the nurse assess? (Select all that apply.) a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseau's sign

A,B,C uMetabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Patients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate and depth. A positive Trousseau's sign is associated with alkalosis. Decreased urine output is not a manifestation of metabolic acidosis.

A nurse plans care for a patient with burn injuries. Which interventions would the nurse implement to prevent infection in the patient? (Select all that apply.) a.Ask all family members and visitors to perform hand hygiene before touching the patient. b.Carefully monitor burn wounds when providing each dressing change. c.Clean equipment with alcohol between uses with each patient on the unit. d.Allow family members to only bring the patient plants from the hospital's gift shop. e.Use aseptic technique and wear gloves when performing wound care.

A,B,E, ´To prevent infection in a patient with burn injuries the nurse would ensure that everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The patient would have disposable equipment that is not shared with another patient, and plants would not be allowed in the patient's room.

A nurse plans care for a patient with burn injuries. Which interventions would the nurse include in this patient's plan of care to ensure adequate nutrition? (Select all that apply.) a.Provide at least 5000 kcal/day. b.Start an oral diet on the first day. c.Administer a diet high in protein. d.Collaborate with a registered dietitian. e.Offer frequent high-calorie snacks.

A,C,D,E ´A patient with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse would collaborate with a registered dietitian to ensure that the patient receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy would be delayed until GI motility resumes.

You walk into your patients room who is diagnosed with a DVT and you assess tachycardia, tachypnea, hypoxia. What should you do first for your patient?

Assess Airway and Apply Oxygen

The facility you work for looses power, the back up generator turns on, what is priority?

Assess oxygenation working, then assess all monitors and IV pumps are in plugs associated with the generator

You go to asses your patient with spinal cord injury and they are experiencing hypertension, headache, and flushed skin. What complication are they experiencing?

Autonomic Dysreflexia

A nurse is triaging patients in the emergency department (ED). Which patient would the nurse prioritize to receive care first? a. A 22-year-old with a painful and swollen right wrist b. A 45-year-old reporting chest pain and diaphoresis c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F (38.8° C)

B A patient experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other patients are more stable.

A nurse assesses a patient admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding would alert the nurse to a potential complication? a.Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b.Urine output of 20 mL/hr c.Productive cough with white pulmonary secretions d.Core temperature of 100.6° F (38° C)

B ´A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the patient may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.

A nurse is caring for a patient who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3- 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values? A. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

B uArterial blood gas values indicate that the patient has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this patient has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred.

The emergency department team is performing cardiopulmonary resuscitation on a patient when the patient's spouse arrives at the emergency department. Which action would the nurse take first? a.Request that the patient's spouse sit in the waiting room. b.Ask the spouse if he wishes to be present during the resuscitation. c.Suggest that the spouse begin to pray for the patient. d.Refer the patient's spouse to the hospital's crisis team.

B uIf resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the patient or to begin to have closure.

A nurse is assessing a patient who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance would the nurse assess? A. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek's sign

B uThe pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek's sign are manifestations of the electrolyte imbalances that accompany alkalosis.

The client admitted to the ED has a serum potassium level of 6.0 mEq/L. The nurse should assess for which finding? SATA Hyperthermia Bounding pulse Weak, irregular pulses Increased GI motility

Bounding pulse, Increased GI Motility

The nurse is teaching a patient how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the patient demonstrates a correct understanding of the teaching? A. "I should leave the drainage bag above the level of my abdomen." b. "I could flush the tubing with normal saline if the flow stops." c. "I should take a stool softener every morning to avoid constipation." d. "My diet should have low fiber in it to prevent any irritation."

C uInflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the patient. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.

An emergency room nurse is triaging victims of a multi-casualty event. Which patient would receive care first? a.A 30-year-old distraught mother holding her crying child b.A 65-year-old conscious male with a head laceration c.A 26-year-old male who has pale, cool, clammy skin d.A 48-year-old with a simple fracture of the lower leg

C uThe patient with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

A patient is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion

C uWith an optimal fluid balance, the patient will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.

A nurse uses the rule of nines to assess a patient with burn injuries to the entire back region and left arm. How would the nurse document the percentage of the patient's body that sustained burns? a.9% b.18% c.27% d.36%

C ´According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the patient received burns to the back (18%) and one arm (9%), totaling 27% of the body.

After assessing an older adult patient with a burn wound, the nurse documents the findings as follows:Vital Signs Laboratory Results Wound Assessment Heart rate: 110 beats/minBlood pressure: 112/68 mm HgRespiratory rate: 20 breaths/minOxygen saturation: 94%Pain: 3/10 Red blood cell count: 5,000,000/(5 ´ 1012/L)White blood cell count: 10,000/mm3 (10 ´ 109/L)Platelet count: 200,000/mm3 (200 ´ 109/L) Left chest burn wound, 3 ´ 2.5 ´ 0.5 cm, wound bed pale, surrounding tissues with edema present a.Assess the patient's skin for signs of adequate perfusion. b.Calculate intake and output ratio for the last 24 hours. c.Prepare to obtain blood and wound cultures. d.Place the patient in an isolation room.

C ´Older patients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse would assess for this and for systemic infection before the patient manifests sepsis. Placing the patient in an isolation room, calculating intake and output, and assessing the patient's skin would all be implemented but these actions do not take priority over determining whether the patient has an infection.

A nurse reviews the following data in the chart of a patient with burn injuries:Admission Notes Wound Assessment 36-year-old female with bilateral leg burnsNKDAHealth history of asthma and seasonal allergies. Bilateral leg burns present with a white and leatherlike appearance. No blisters or bleeding present. Patient rates pain 2/10 on a scale of 0 to 10. Based on the data provided, how would the nurse categorize this patient's injuries? a.Partial-thickness deep b.Partial-thickness superficial c.Full thickness d.Superficial

C ´The characteristics of the patient's wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

.A nurse cares for a patient with a burn injury who presents with drooling and difficulty swallowing. What action would the nurse take first? A. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d.Measure abdominal girth and auscultate bowel sounds

C ´Inhalation injuries are present in 7% of patients admitted to burn centers. Drooling and difficulty swallowing can mean that the patient is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

A nurse cares for a patient who has facial burns. The patient asks, "Will I ever look the same?" How would the nurse respond? a."With reconstructive surgery, you can look the same." b."We can remove the scars with the use of a pressure dressing." c."You will not look exactly the same but cosmetic surgery will help." d."You shouldn't start worrying about your appearance right now."

C ´Many patients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse would provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The patient and the family would be taught the expected cosmetic outcomes.

Your patient is 4 hours post CABG surgery and you notice a decreased output from the chest tubes as well as muffled heart sounds. What complication is occurring?

Cardiac Tamponade

Your patient just returned following a cardiac cath. What should you be assessing and implementing during the post-cath phase?

Check peripheral pulses and circulation in the affected extremity. Measure the client's vital signs every 15 minutes Keep the client's affected extremity straight. Have the client remain in bed up to 6 hours

Your patient hep A has incontinent liquid diarrhea and urine, which type of precautions are necessary when the CNA goes in to provide cares for the patient?

Contact precautions

Your patient had an MI 4 days ago, what is the most concerning assessment finding: Troponin 3.3 Creat 5.5 Potassium 3.6 Myoglobin 0

Creat 5.5

The low pressure alarm on the ventilator is alarming. What common problems may be triggering the alarm?

Cuff deflated, disconnection of ventilator tubing, patient extubation

You're charge nurse in the ED during mass causality and have to assign triage level. Assign the following patients: Cuts all over arm and leg, small head laceration GCS 3, weak pulse, shallow breathing Displaced arm fracture, good peripheral pulses Open fracture to left leg, with cyanotic toes

Cuts all over arm and leg, small head laceration: Green GCS 3, weak pulse, shallow breathing: Black Displaced arm fracture, good peripheral pulses: Yellow Open fracture to left leg, with cyanotic toes: Red

A nurse assesses a patient who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. What action would the nurse take next? a.Administer furosemide (Lasix). b.Perform chest physiotherapy. c.Document and reassess in an hour. d.Place the patient in an upright position.

D ´Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the patient in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in patients who are fluid overloaded, a patient with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.

What's a complication associated with hemodialysis and what are it's signs and symptoms?

Dialysis disequilibrium and headache, altered LOC, nausea, restlessness

Your patient was struck by lightening what is priority upon arrival to hospital?

EKG to assess for cardiac dysrhythmias.

nThe homeless patient is having chest pain, EKG reveals some ST elevation and Troponin is 2.3. The physician orders transfer to a facility that has a cath lab STAT. What protects the facility for this transfer?

EMTALA

Which shock is most common in early phase of burn injury? In acute phase?

Early:Hypovolemic Acute: Septic

Patient was struck by lightening

Electrical

Entire epidermis and dermis; skin will not grow back

Full Thickness burn

What can we do to prevent ventilator associated pneumonia (VAP)?

Hand hygiene, oral care, elevate head of the bed, suctioning, GI prophylaxis, DVT prophylaxis

What are ways to prevent infection? (in the case of major burn victim open skin)

Hand washing, change gloves between each dressing change, disposable dishware, limit sick contacts, no fresh fruit/flowers

Acute phase of burns Nutrition

High calorie/ High protein

What should our patient prepare to do prior to CABG surgery scheduled in 1 week.

Hold all anticoagulants, remove chest and leg hair with clippers, wash with prescribed chlorhexidine wash day of surgery, determine pain management preferences, understand Incentive spirometer use

What signs and symptoms will we see with neurogenic shock?

Hypothermia, bradycardia, hypotension, loss of tone below level of injury

The patient comes in to ED following a fall from a roof, what order are we going to assess the patient upon arrival.

Immobilize first then Airway, breathing, circulation, deformity, expose, full vitals

What is biggest priority in rehabilitation phase when preparing for wound care?

Infection Control Pain Management

The patient has potassium level of 5.8 and has non sustained V.Tach with a pulse. What treatment should the nurse prepare for.

Insulin and D5W administration

Triponin

Less then .03

Myoglobin

Less then 90

What acid/base and electrolyte abnormalities are common in beginning stages of renal failure patients?

Metabolic acidosis, hyperkalemia, hyponaetremia

List Signs/Symptoms with Hypokalemia

Muscle weakness, bradycardia, dysrhythmias, decreased bowel sounds, fatigue

List the lab diagnostic associated with each diagnosis:Myocardial infarctionLiver CirrhosisAcute Kidney InjuryPancreatitisSepsis

Myocardial infarction: TroponinLiver Cirrhosis: AST/ALTAcute Kidney Injury: CreatininePancreatitis: Amylase/LipaseSepsis: Lactic Acid

Your patient presents with acute pancreatitis what can you expect to be ordered by the physician?

NPO, IV fluid hydration

The patient is to receive a second unit of blood and is experiencing shortness of breath, increased work of breathing, and pulse ox of 88%. What should the nurse do first?

Notify provider

Your terminally ill patient has BP of 78/55, HR 44, RR 29, pulse ox 72%. What will the nurse do as priority.

Notify the family of worsening condition and imminent death.

Entire epidermis and varying degrees of dermis

Partial Thickness

Which patient should the nurse see first: Male with small hand laceration Child crying with fever 101.4 Cancer patient vomiting for last half hour Patient recently discharged with tachycardia, shortness of breath

Patient recently discharged with tachycardia, shortness of breath

pH 7.55, PaCO2 25, HCO3- 22

Respiratory Alkalosis, Uncompensated

Which of the following signs and symptoms of increased ICP after head trauma would appear first? 1. Bradycardia 2. Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure

Restlessness and Confusion

Patient has cough, wheezing, and hypoxia. What should nurse plan to implement?

Secure airway with intubation

In what order should we do first for anaphylactic shock: Apply oxygen Stop allergen Give diphenhydramine Give methylprednisolone Give EPI

Stop allergen, oxygen, epi, methylprednisolone, dephenhydramine

Epidermis is mildly damaged

Superficial burn

Your patient had a thoracentesis 2 hours ago. You go to conduct your assessment and notice complications, which assessment findings may you be seeing?

Tachycardia, hypotension, respiratory distress, tachypnea, hypoxia, diminished breath sounds

Your patient comes in to the ED with deviated trachea, absent breath sounds on left side, respiratory distress and hemodynamic instability. What chest trauma do they have and what will the RN prepare to assist in first?

Tension Pneumothorax Needle decompression then Chest tube insertion

Pot of boiling water spills onto child

Thermal burn

At which level of spinal cord injury do we worry about respiratory compromise? A. T7 B. T10 C. L5 D. S1

Thoracic 7

Acute phase of Burns what are neutopenia percaucions

When wound care changes glove between wounds

Which electrolyte abnormality do we see with patient post whipple procedure?

hypocalcemia