Module D Shocks and Burn Practice Questions

a nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following statements is appropriate ? A) large incisions will be made in the eschar to improve circulation B) this procedure involves placing the client into shower and removing dead tissue C) a piece of healthy skin will be removed from an unburned area and grafted over the burned area D) dead tissue will be non-surgical removed.

A) Large incisions will be made in the eschar to improve circulation. an escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has deep burn and is experiencing excessive swelling.

a client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are as follows: HR 132, RR 28, BP 84/58, T 97F, O2 sat 89%. Which prescription should the nurse implement first? A) administer 1L 0.9% NS IV B) draw a complete blood count with H/H C) obtain an abdominal X-RAY D) insert an indwelling urinary catheter.

A) administer 1L 0.9% NS IV VS consistent with fluid volume deficit due to bleeding/hypovolemic shock IV fluid replacement is used to expand/replace blood volume and normalize vital signs.

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A) airway obstruction. B) infection. C) fluid imbalance. D) paralytic ileus.

A) airway obstruction. burns of the head, neck, and chest often involve damage to the pulmonary tree due to heart as well as smoke and soot inhalation. this can result in severe respiratory difficulty.

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). which of the following findings should the nurse expect? A) excessive thrombosis and bleeding B) progressive increase in platelet production C) immediate sodium and fluid retention. D) increased clotting factors

A) excessive thrombosis and bleeding The nurse should expect excessive thrombosis and bleeding of mucous membranes because both DIC impairs both coagulation and anticoagulation pathways.

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? A) increased heart rate B) widening pulse pressure C) increased deep tendon reflexes D) pulse oximetry 96%

A) increased heart rate The nurse should anticipate an increased HR as an early indication of shock because the body attempts to compensate for decreased circulatory volume.

which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate? A) urine output > 30ml/hr. B) systolic blood pressure >110 mmHg C) diastolic blood pressure >90 mmHg D) respiratory rate of 20 breaths/min

A) urine output > 30 ml/hr urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock.

When should the nurse initiate rehabilitation plans for the client who has severe burns? A) immediately after the burn has occurred. B) after the client's circulatory status has been stabilized. C) after grafting of the burn wounds has occurred. D) after the client's pain has been eliminated.

B) after the client's circulatory status has been stabilized. rehabilitation efforts are implemented as soon as the client's condition is stabilized. early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make adjustments necessary to return to optimal state of health and independence.

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? A) mottled skin. B) blood pressure 115/68 mmHg. C) heart rate 160/min. D) hypokalemia

B) blood pressure 115/68 mmHg the sympathetic nervous system is stimulated, resulting in the releas of epinephrine and norepinephrine. these catecholamines help maintain the client's BP remains within normal limits during compensatory stage.

A client is admitted to the emergency department with a full thickness burn to the right arm. Upon assessment, the arms is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. what should the nurse do next? A) administer morphine sulfate IV push for severe pain. B) Call the health care provider to report the loss of radial pulse. C) continue to assess the arm every hour for any additional changes. D) instruct the client to exercise the fingers and the wrist.

B) call the health care provider to report the loss of radial pulse. circulation can be impaired by circumferential burns and edema, causing compartment syndrome. Early recognition and treatment of impaired blood supply is key. The HCP should be informed since an escharotomy is frequently performed to restore circulation.

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A) urinary output 25 mL/hr. B) difficulty swallowing. C) heart rate 122/min. D) pain of a 6 on a scale of 0 to 10.

B) difficulty swallowing. an indication that the client's airway is obstructed.

A nurse is caring for a client in a critical are unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? A) sudden lethargy. B) muffled heart sounds. C) flattened neck veins. D) bradycardia

B) muffled heart sounds. Muffled heart sounds are a key indicator of cardiac tamponade because of the excess amount of fluid surrounding the heart.

Which is an advantage of using biologic burn grafts such as porcine (pigskin) grafts? porcine grafts: A) encourage the formation of tough skin. B) promote the growth of epithelial tissue. C) provide for permanent wound closure. D) facilitate the development of subcutaneous tissue.

B) promote the growth of epithelial tissue. they enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase motility, and help prevent infection.

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episodes of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect? A) the laboratory values are within the expected reference range. B) the laboratory values are prolonged. C) the laboratory values are decreased. D) the laboratory values are the same as previous test values.

B) the laboratory values are prolonged. These laboratory values measure clotting time. Because DIC results in the formation of multiple, small clots that consume key clotting factors, the nurse should expect the laboratory values to be prolonged.

A nurse in an emergency department is reviewing medical record of a client who has extensive burn injury. Which of the following laboratory results should the nurse expect? A) metabolic alkalosis. B) hypervolemia. C) hyperkalemia. D) low hemoglobin.

C) Hyperkalemia The nurse should expect a client who has a burn injury to experience hyperkalemia due to the release of potassium from damaged cells.

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A) hypotension. B) anuria. C) increased respiratory rate. D) decreased LOC.

C) Increased respiratory rate. when shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues.

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following action should the nurse take first? A) assess the client's LOC. B) administer epinephrine. C) auscultate for wheezing. D) monitor for hypotension.

C) auscultate for wheezing. When using ABC approach, the priority is assessing the client's respiratory rate. bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.

What is the most important goal of nursing care for a client who is in shock? A) manage fluid overload. B) manage increased cardiac output. C) manage inadequate tissue perfusion. D) manage vasoconstriction of vascular beds.

C) manage inadequate tissue perfusion. nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion.

a nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A) "DIC is controllable with lifelong heparin usage." B) "DIC is characterized by an elevated platelet count" C) "DIC is caused by abnormal coagulation involving fibrinogen" D) "DIC is a genetic disorder involving a vitamin K deficiency"

D) "DIC is caused by abnormal coagulation involving fibrinogen" DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrogen faster than the body can produce them, increasing the risk of hemorrhage.

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rules f nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)? A) 9% B) 18% C) 36% D) 54%

D) 54% each arm represents 9% of the client's TBSA and each leg represents 18% of the client's TBSA totaling 54%.

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following intervention should the nurse perform first? A) clean and dress the wound. B) administer pain medication. C) administer tetanus booster. D) administer IV fluids.

D) Administer IV fluids. using the ABC framework, the priority action should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output.

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which findings indicates to the nurse that the client may be developing hypovolemic shock? A) decrease in the respiratory rate from 20 to 16/min. B) decrease in urinary output from 50mL to 30mL per hour. C) increase in the temperature from 99.5F to 101.5F D) increase in heart rate from 88 to 110/min.

D) increase in the heart rate from 88 to 110/min. in the first stage of shock, the heart rate is >100/min. IN the final stage, the heart rate becomes very erratic and may develop asystole.

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hour following a burn injury? A) dextrose 5% in water. B) dextrose 5% in 0.9% sodium chloride C) 0.9% sodium chloride D) lactated ringer's

D) lactated ringer's LR is used in the first 24 hour following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.

A nurse in an emergency department is caring for a client who has deep partial - and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury? A) initiate fluid resuscitation. B) medicate for pain. C) insert an indwelling urinary catheter. D) maintain the airway.

D) maintain the airway. The client is at risk for respiratory obstruction. Using ABC approach to client care the first action the nurse should take to ensure that the client has a patent airway.

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? A) confusion B) blood pressure 84/50 mmHg C) anuria D) petechiae

a) confusion confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.