Medsurg II-Exam 3
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours?
600 mL/h
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
938 mL/hr
CD4+ T-cell count AIDS dx
<200 cells/mcl
Which of the following statements about myocardial infarction pain is incorrect? A. It is relieved by rest and inactivity. B. It is substernal in location. C. It is sudden in onset and prolonged in duration. D. It is viselike and radiates to the shoulders and arms.
A (A: MI pain continues despite rest and medications. B: The pain occurs substernally or at the chest area. C: MI pain occurs suddenly and is prolonged in duration. D: The pain grips the patient like a vise and radiates towards the arms or the shoulders.)
Myocardial cell damage can be reflected by high levels of cardiac enzymes. The cardiac-specific isoenzyme is: A. Alkaline phosphatase B. Creatine kinase (CK-MB) C. Myoglobin D. Troponin
B (B: CK-MB is the isoenzyme for the heart muscle and the cardiac-specific enzyme. A: Alkaline phosphatase is not part of the creatine kinase isoenzymes. C: Myoglobin is a heme protein that helps transport oxygen. D: Troponin regulates the myocardial contractile process.)
A patient has just arrived in the emergency department after an electrical burn from exposure to a high- voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light
C
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patients lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringers solution. d. Administer the ordered hydromorphone (Dilaudid).
a
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a.Insert a feeding tube and initiate enteral feedings. b.Infuse total parenteral nutrition via a central catheter. c.Encourage an oral intake of at least 5000 kcal per day. d.Administer multiple vitamins and minerals in the IV solution.
a
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.
a
An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings.
a
The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a.The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b.The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c.The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d.The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.
a
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a.Continue to monitor the urine output. b.Monitor for increased white blood cells (WBCs). c.Assess that blisters and edema have subsided. d.Prepare the patient for discharge from the burn unit.
a
The nurse is caring for a patient after a kidney transplant. Which finding prompts the nurse to quickly alert the health care provider about a probable hyperacute rejection? A. There is no urine output and problems occur immediately B. Blood urea nitrogen and creatinine show trend for elevation C. Patient reports some tenderness at the incision site D. Patient has an allergic reaction to the transplant medications
a
What precation or intervention has the highest priority for a patient going home on maintenance drugs after receiving a kidney transplant? A. Monitoring for bacterial and fungal infections B. Avoiding the use of table salt C. Measuring abdominal girth daily D. Avoiding blood donation
a
Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a.A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. b.A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c.A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d.A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns
a
Which patient should the nurse assess first? a.A patient with smoke inhalation who has wheezes and altered mental status b.A patient with full-thickness leg burns who has a dressing change scheduled c.A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d.A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
a
Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a drug should include which of the following actions first? A. Administering oxygen B. Inserting an I.V. catheter C. Obtaining a complete blood count (CBC) D. Taking vital signs
a (A: Giving oxygen would be the best first action in this case. B: If the client doesn't already have an I.V. catheter, one may be inserted now if anaphylactic shock is developing. C: Obtaining a CBC wouldn't help the emergency situation. D: Vital signs then should be checked and the physician immediately notified.)
Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform? A. Removing the stinger by scraping it. B. Applying a cold compress. C. Taking an oral antihistamine. D. Calling the 911.
a (A: Since the stinger will continue to release venom into the skin, removing the stinger should be the first action that the nurse should direct to the client. B&C: After removing the stinger, Antihistamine and cold compress follow. D: The caller should be further advised about symptoms that require 911 assistance.)
The nurse advises a patient that sublingual nitroglycerin should alleviate angina pain within: A. 3 to 4 minutes. B. 10 to 15 minutes. C. 30 minutes. D. 60 minutes.
a (Nitroglycerin given sublingually alleviates angina pain within 3 minutes.)
What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. a. the RR intervals are relatively consistent b. one P wave precedes each QRS complex c. 4-8 complexes occur in a 6-sec strip d. the ST segment is higher than the PR interval e. The QRS complex ranges from 0.12-0.20 second
a, b (The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. The number of complexes in a 6 second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second.)
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a.Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.
b
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a.Encourage the patient to cough and auscultate the lungs again. b.Notify the health care provider and prepare for endotracheal intubation. c.Document the results and continue to monitor the patient's respiratory rate. d.Reposition the patient in high-Fowler's position and reassess breath sounds.
b
A patient who had a kidney transplant 5 years ago is experiencing progressive reduced function of the organ. Which intervention is appropriate for this patient? A. Patient should be admitted to intensive care for observation and possible dialysis B. Patient should be educated about retransplantation; related living donor should be sought C. Drug management may limit the damage and allow the graft to be maintained D. Patient should be immediately prepped for surgical removal of the organ
b
A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, Im sorry that Im still alive. My life will never be normal again. Which response by the nurse is best? a. Most people recover after a burn and feel satisfied with their lives. b. Its true that your life may be different. What concerns you the most? c. It is really too early to know how much your life will be changed by the burn. d. Why do you feel that way? You will be able to adapt as your recovery progresses.
b
The intensive care nurse is caring for a patient who just received a kidney transplant from a related donor. The nurse notices hypotension and excessive diuresis, 1000 mL, greater than intake over the past 12 months. At this point, what is the primary concept that affects graft survival? A. Infection B. Perfusion C. Elimination D. Cellular regulation
b
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a.First-degree skin destruction b.Full-thickness skin destruction c.Deep partial-thickness skin destruction d.Superficial partial-thickness skin destruction
b
While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a.Use sterile gloves when removing old dressings. b.Wear gowns, caps, masks, and gloves during all care of the patient. c.Administer IV antibiotics to prevent bacterial colonization of wounds. d.Turn the room temperature up to at least 70° F (20° C) during dressing changes.
b
Which action by a new registered nurse (RN) who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias? a. Prepares defibrillator settings at 360 joules for a patient whose monitor shows asystole. b. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block
b (Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more teaching about treatment of heart dysrhythmias. The RN should hold the diltiazem until discussing it with the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating.)
Diagnosis of HF is usually confirmed by: a. chest x-ray b. echocardiogram c. electrocardiogram d. ventriculogram
b (B: An echocardiogram is usually performed to confirm the diagnosis of HF, and identify the underlying cause. A: Chest x-ray findings are also basis of the diagnosis of HF, but it is not the confirmatory diagnostic test. C: ECG is obtained to assist in the diagnosis. D: Ventriculogram is not a part of the diagnostic tests for HF.)
The leading cause of death in fire victims is believed to be: A. Cardiac arrest B. Carbon monoxide intoxication C. Hypovolemic shock D. Septicemia
b (B: Before the flames can reach a victim smoke from the fire would reach them and suffocate them first. A: Cardiac arrest is a disease that can occur later on in a burn patient. C: Hypovolemic shock is a consequence of the burn injury. D: Septicemia could occur late in the process of an inappropriately treated burn injury.)
The primary cause of HF is: a. arterial HTN b. coronary atherosclerosis c. myocardial dysfunction d. valvular dysfunction
b (B: Coronary atherosclerosis is the primary cause of heart failure. A: Arterial hypertension is not the primary cause of heart failure. C: Myocardial dysfunction is not a cause of heart failure. D: Valvular dysfunction is not the primary cause of heart failure.)
A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? a. breathe deeply, regularly, and easily b. inhale deeply and cough forcefully every 1-3 secs c. lie down flat in bed d. remove any metal jewlery
b (Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.)
A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. document the finding and monitor the patient. c. give atropine per agency dysrhythmia protocol. d. prepare the patient for temporary pacemaker insertion.
b (First-degree atrioventricular block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary.DIF: Cognitive Level: Apply (application))
While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: a. increase the IV infusion rate b. notify the physician promptly c. increase the O2 concentration d. administer a prescribed analgesic
b (PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.)
A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Give atropine per agency dysrhythmia protocol. d. Provide supplemental O2 via non-rebreather mask.
b (The patient's clinical manifestations indicate pulseless electrical activity, and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.)
A patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first? a. Give epinephrine (Adrenalin) IV. b. Perform immediate defibrillation. c. Prepare for endotracheal intubation. d. Ventilate with a bag-valve-mask device.
b (The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, begin chest compressions. The other actions may also be appropriate but not first.)
Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as telemetry technicians on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Observe heart rhythms for multiple patients who have telemetry monitoring. c. Monitor a patient's level of consciousness during synchronized cardioversion. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.
b (UAP serving as telemetry technicians can monitor heart rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice.)
The nurse notes that a patient's heart monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions
b (Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions are multifocal or that the R-on-T phenomenon is occurring.DIF: Cognitive Level: Apply (application))
When ventricular fibrillation occurs in a CCU, the first person reaching the client should: a. administer O2 b. defibrillate the pt c. initiate CPR d. administer sodium bicarbonate IV
b (Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be terminated immediately by precordial shock (defibrillation). This is usually a standing physician's order in a CCU.)
Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.
b (When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient.)
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a.Bananas b.Orange gelatin c.Vanilla milkshake d.Whole grain bagel
c
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a.Assess oral temperature. b.Check a potassium level. c.Place on cardiac monitor. d.Assess for pain at contact points.
c
During surgery, a patient undergoing a heart transplant experiences rejection of the organ. What type of rejection is this? A. Acute B. Chronic C. Hyperacute D. Transplant
c
How does the immune system respond to a graft when a transplant rejection occurs? A. Collateral circulation develops and the transplanted organ becomes engorged B. Opportunistic infections develop because the body is immunosuppressed C. Host's immune system starts inflammation and immunologic actions to destroy nonself cells D. Systemic tissue destruction occurs because of inability to differentiate self from nonself cells
c
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a.Monitor urine output every 4 hours. b.Continue to monitor the laboratory results. c.Increase the rate of the ordered IV solution. d.Type and crossmatch for a blood transfusion
c
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a.Hematocrit 53% b.Serum sodium 147 mEq/L c.Serum potassium 6.1 mEq/L d.Blood urea nitrogen 37 mg/dL
c
A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's vital signs including O2 saturation.
c (Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with O2 administration. The other actions are also important and should be implemented rapidly.)
Fluids shifts during the first week of the acute phase of a burn injury that cause massive cell destruction result in: A. Hypernatremia B. Hypokalemia C. Hyperkalemia D. Hypercalcemia
c (C: Immediately after burn injury hyperkalemia results from massive cell destruction. A: Hyponatremia and not hypernatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space. B: Hypokalemia, instead hyperkalemia, occurs immediately after burn injury. D: There is no hypercalcemia in a burn injury.)
A 19-yr-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? a. Insert an IV catheter for emergency use. b. Start supplemental O2 at 2 to 3 L/min via nasal cannula. c. Ask the patient about current stress level and caffeine use. d. Have the patient taken to the nearest emergency department (ED).
c (In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. The patient is hemodynamically stable, so there is no indication that the patient needs supplemental O2, an IV, or to be seen in the ED.)
When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: a. the presence of occasional coupled beats b. long pauses in an otherwise regular rhythm c. a continuous and totally unpredictable irregularity d. slow but strong and regular beats
c (In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions.)
Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure prevents or minimizes the risk for sudden cardiac death. b. The procedure uses cold therapy to stop the formation of the flutter waves. c. The procedure uses electrical energy to destroy areas of the conduction system. d. The procedure stimulates the growth of new conduction pathways between the atria.
c (Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect.)
A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Prepare to give IV amiodarone per agency dysrhythmia protocol. d. Perform synchronized cardioversion per agency dysrhythmia protocol.
c (The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.)
Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more teaching about the care of patients with ICDs? a. The nurse administers amiodarone (Cordarone) to the patient. b. The nurse helps the patient fill out the application for obtaining a Medic Alert device. c. The nurse encourages the patient to do active range of motion exercises for all extremities. d. The nurse teaches the patient that sexual activity can be resumed when the incision is healed.
c (The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.)
The action of which cell types must be suppressed to prevent acute rejection of transplanted organs? SATA A. Eosinophils B. Suppressor T-cells C. Natural killer cells D. Cytotoxic/cytolytic T-cells E. Helper/inducer T-cells F. Neutrophils
c, d
A patient is admitted to the hospital for acute rejection of a kidney transplant that was performed 2 months ago. Which intervention is appropriate for this patient? A. Immediate removal of the transplanted kidney B. Grief and loss counseling to prepare for loss of organ C. Magnetic resonance imaging of organ D. Organ biopsy to diagnose impaired function
d
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.
d
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patients skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patients orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.
d
A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving? a. Im glad the scars are only temporary. b. I will avoid using a pillow, so my neck will be OK. c. I bet my boyfriend wont even want to look at me anymore. d. Do you think dark beige makeup foundation would cover this scar on my cheek?
d
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a.Check skin turgor. b.Monitor daily weight. c.Assess mucous membranes. d.Measure hourly urine output.
d
Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a.Blood pressure is 95/48 per arterial line. b.Serous exudate is leaking from the burns. c.Cardiac monitor shows a pulse rate of 108. d.Urine output is 20 mL per hour for the past 2 hours.
d
Eight hours after a thermal burn covering 50% of a patients total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.
d
The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)
d
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a.Keep the right arm in a position of comfort. b.Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.
d
When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a. isoelectric ST segment. b. QT interval of 0.38 second. c. PR interval of 0.18 second. d. QRS interval of 0.14 second.
d (Because the normal QRS interval is less than 0.12 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The PR interval and QT interval are within normal range and ST segment should be isoelectric (flat).)
What is the best method to prevent the spread of infection when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Soak the dressing in sterile normal saline. c. Apply antibiotic ointment over the wound. d. Wash hands and properly dispose of soiled dressings.
d (Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. Sterile glove and sterile saline use during wound care will not necessarily prevent spread of infection. Applying antibiotic ointment will treat the bacteria but not necessarily prevent the spread of infection.)
Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose of 243 mg/dL b. Serum sodium of 134 mEq/L c. Serum chloride of 92 mEq/L d. Serum potassium of 2.9 mEq/L
d (Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values are also abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction.)
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. b. ventricular fibrillation. c. sinus tachycardia. d. ventricular tachycardia.
d (The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.DIF: Cognitive Level: Apply (application))
The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due b. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago d. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due
d (The frequent firing of the ICD indicates that the patient's ventricles are very irritable and the priority is to assess the patient and give the amiodarone. The other patients can be seen after the amiodarone is given.)
A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.
d (The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate.)
The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states a. "It will be several weeks before I can return to my usual activities." b. "I will avoid cooking with a microwave oven or being near one in use." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side until I see the health care provider."
d (The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.)
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 8 to 10 for adequate protection. b. Water resistant sunscreens will provide good protection when swimming. c. Increase sun exposure by no more than 10 minutes a day to avoid skin damage. d. Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).
d (The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. No sunscreen is completely water resistant. Sunscreens classified as water resistant sunscreens still need to be reapplied after swimming. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased.)
