NUR 493 EAQ #3

The nurse is teaching a student nurse about treatment for sepsis. Which response by the student indicates a need for further teaching?

"Antibiotics should be delayed until the causative organism is known." More specific antibiotics may be ordered once the organism has been identified, but administration of antibiotics should not be delayed. Broad-spectrum antibiotics are given first. Antibiotics are an important early component of therapy and should be started in the first hour. The nurse should obtain blood cultures before antibiotics are started.

Which explanation is correct regarding the reason a patient with multiple organ dysfunction syndrome (MODS) may develop blood in the stool?

"Decreased oxygen to the gastric mucosa leads to breakdown." Decreased perfusion leads to breakdown of the protective gastrointestinal (GI) mucosa, leading to GI bleeding, risk for ulceration, and bacterial movement from the GI tract into the circulation. The statement that acid production is increased due to the enteral feedings is an incorrect statement. Decreased gastric motility is common in critical illness and leads to paralytic ileus and abdominal distention, not GI bleeding. The medications used to treat MODS do not include GI bleeding as a side effect.

Which statement from a co-worker regarding the fluid and electrolyte shifts that occur during burn injuries requires correction by the nurse?

"Exudate is an example of second spacing." Exudate is an example of third spacing. Accumulation of fluid in the interstitium is second spacing. Edema and blister formation are examples of third spacing. Third spacing is the movement of fluid to the areas with no or minimal fluid.

A nurse is teaching a group of parents how to reduce the risk for scalding and inhalation burns. Which statement made by a participant indicates a need for further teaching?

"I should light candles near an open window." Candles should not be left unattended or placed in an open window because this increases the risk for a fire. The water heater should be set at no more than 120°F to reduce the risk for burning. Hard-wired smoke detectors do not require batteries; therefore, this increases the safety of the home environment. Water temperature should be checked with the back of the hand or a bath thermometer.

Which explanation will the nurse give when teaching a patient who is at risk for respiratory failure about the benefits of pursed lip breathing?

"It increases the saturation of oxygen." Pursed lip breathing increases the saturation of oxygen (SaO2) by slowing respirations, allowing more time for expiration, and preventing the small bronchioles from collapsing. Pursed lip breathing may slightly increase work of breathing since it takes more effort to exhale against the positive pressure created by pursing the lips. Pursed lip breathing prolongs expiration. Although pursed lip breathing may improve gas exchange, accessory muscles such as the diaphragm, intercostal muscles, and sternocleidomastoid muscles may still be activated to improve oxygenation as well.

A patient with partial-thickness burns is being treated with zolpidem, and the family inquires why the patient is receiving the medication. Which responses by the nurse are appropriate? Select all that apply.

"It is used to provide short-term amnesic effects." "It is used to help promote sleep." "It is used to reduce anxiety." Zolpidem is a sedative-hypnotic medicine and is given to patients suffering from burns. Zolpidem promotes sleep, reduces anxiety, and provides short-term amnesic effects. Nutritional support is used to promote wound healing. Anticoagulants are used to prevent thromboembolism.

Which statement by the nurse explains the basis for enteral versus parenteral feedings for a patient with multiple organ dysfunction syndrome (MODS)?

"Providing feedings through a gastrostomy tube is safer and has a lower rate of infection." In MODS, the enteral route is preferred for feedings because they are safer, have a lower rate of infection and complications, and are more efficient. The statement that IV feedings cannot provide enough support is an inaccurate statement. While issues related to MODS could make IV access difficult, this is not the best explanation. Physicians may have differing preferences; however, this is not the best response to this question.

Which instruction will the nurse include when teaching a patient how to do huff coughing?

"Say the word 'huff' while coughing." During huff coughing, the patient says the word "huff" while coughing, which keeps the glottis from closing and improves the effectiveness of the cough. Pursed lip breathing may be used by patients to improve ventilation but is not a coughing technique. During a staged cough, the patient bends forward and presses a pillow into the diaphragm. The tripod position improves ventilation by increasing lung expansion but is not a coughing technique.

The family of a patient being treated for multiple organ dysfunction syndrome (MODS) asks the nurse why the patient is being sedated and placed on mechanical ventilation. Which explanation by the nurse is correct?

"Sedation and mechanical ventilation help to decrease oxygen demands and increase oxygen delivery to organs." Hypoxemia is common in MODS; sedation and mechanical ventilation help to decrease oxygen demands and maintain adequate oxygen delivery to organs. While decreasing oxygen demands may help to prevent the failure of other systems, it does not necessarily allow the gastrointestinal system to rest. Not all patients with MODS require sedation and mechanical ventilation. Sedation and mechanical ventilation do not necessarily prevent heart attacks.

Which statement is correct regarding the difference between systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

"Shock leads to SIRS, and SIRS causes MODS." Any type of shock triggers the systemic inflammatory response. Generalized inflammation in organs remote from the initial shock is SIRS. MODS results from SIRS. Both SIRS and MODS are reversible in the early stages. SIRS is caused by some kind of injury to the body such as sepsis, ischemia, infarction, and injury; SIRS can lead to MODS if not treated. In SIRS, a type of shock triggers a systemic inflammatory response, after which the body's homeostasis fails. In MODS, homeostasis fails and medical intervention is needed.

Which instruction will the nurse give a patient with chronic obstructive pulmonary disease (COPD) who shows increased work of breathing (WOB)?

"Sit with your arms propped on the overbed table." The tripod position will increase the anterior-posterior chest diameter and make it easier to expand the chest, decreasing the WOB and improving gas exchange. Prone positioning is sometimes used for patients with acute respiratory distress syndrome who are receiving mechanical ventilation but would restrict movement of the chest and increase WOB for this patient. The side-lying position can improve oxygenation in a patient with pneumonia on one side, who may be positioned with the good lung down. WOB is usually increased when patients lie down since it is harder to fully expand the chest while lying.

A burn patient's caregiver asks the nurse why an enzymatic debriding agent is being applied to the wounds. Which response by the nurse is appropriate?

"The enzymatic debriding agent helps remove dead tissue from the healthy wound bed." Enzymatic debriding agents are made of natural products like collagen. Enzymatic debriding agents speed up the removal of dead tissue from the healthy wound bed. Skin grafting, a part of wound care, promotes massive blood loss in patients. To prevent this, topical application of epinephrine is advised. Washing the patient's wound with normal saline-moistened gauze removes the old antimicrobial agent. Paraffin gauze dressing protects the re-epithelializing keratinocytes from damage. This dressing resurfaces and closes the open wound bed.

A nurse is teaching a student nurse about multiple organ dysfunction syndrome (MODS). Which statement by the student indicates correct understanding of the concept?

"We would generally see dyspnea, changes in pulmonary artery wedge pressure (PAWP), tachypnea, and a decreasing PaO2/FIO ratio as early signs." The respiratory system is generally the first to show signs of dysfunction in MODS, which means that dyspnea and tachypnea changes in PAWP and a decreasing PaO2/FIO ratio may be early indicators. Metabolic changes are not self-limiting because they can trigger a hypermetabolic response and last for several days. Liver dysfunction often begins long before clinical evidence of the dysfunction is apparent. Prognosis once MODS develops is poor, with a 40% to 60% mortality rate.

Which blood glucose value would be an acceptable level for a patient with multiple organ dysfunction syndrome (MODS) receiving a continuous infusion of insulin?

156 mg/dL Glycemic control is attempted through continuous insulin infusions. The goal is to keep the glucose level between 140 and 180 mg/dL; thus 156 mg/dL would be considered acceptable. The level 68 mg/dL is too low, and 184 mg/dL and 200 mg/dL are too high.

The nurse recognizes which fluid as recommended for the first 24 hours after a burn?

2 to 4 mL lactated Ringer's/kg/%TBSA burned Fluid resuscitation is an important intervention in burn management. It helps to replenish the fluid loss caused by burns and maintain the fluid and electrolyte balance. The fluid recommendation for the first 24 hours is 2 to 4 mL lactated Ringer's/kg/%TBSA burned. A fluid volume of 1 to 2 mL lactated Ringer's/kg/%TBSA burned would be inadequate to meet the patient's requirement. Volumes of 6 to 8 mL lactated Ringer's/kg/%TBSA burned and 8 to 10 mL lactated Ringer's/kg/%TBSA burned may cause fluid overload.

Which range of H2O pressures would the nurse utilize to maintain the patient's endotracheal (ET) tube cuff inflation, stabilize the tube, and ensure adequate tracheal perfusion?

20 to 25cm H2O To ensure adequate tracheal perfusion, the nurse should maintain cuff pressure at 20 to 25 cm H2O. Excess cuff pressure can damage the tracheal mucosa. Lesser cuff pressure may cause the ET tube to become destabilized and extubate.

The nurse is caring for a patient with burns covering the face, the entire right upper extremity, and the right upper trunk area. Using the Rule of Nines, the nurse would calculate the extent of these burns as which percentage?

22.5% Using the Rule of Nines for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area. Eighteen percent, 27%, and 36% are incorrect calculations.

A patient with septic shock weighs 75 kg. The health care provider orders IV fluid resuscitation of 30 mL/kg. How many milliliters will the nurse infuse? Record your answer using a whole number and no punctuation. _________ mL

2250 70 kg x 30 mL/kg = 2250 mL. The nurse should infuse 2250 mL of IV fluid as ordered.

If the patient in shock is to receive 1000 mL of normal saline in two hours, at which rate would the infusion pump be set? Record your answer using a whole number. ___mL/hr

500 For the 1000 mL of normal saline to be infused in two hours, the infusion pump should be set at 500 mL per hour (1000 mL divided by two hours).

An arterial oxygen value (PaO2) less than which number in millimeters of mercury indicates hypoxemic respiratory failure when a patient is receiving an inspired oxygen concentration of more than 60%? Record your answer using a whole number. ______

60 Hypoxemic respiratory failure is commonly defined as a PaO2 of less than 60 mm Hg when the patient is receiving an inspired oxygen concentration of 60% or more. This definition incorporates two important concepts: first, the PaO2 level indicates inadequate oxygen in the arterial blood; second, this PaO2 level exists despite administration of supplemental oxygen at a percentage (60%) that is about three times that in room air (21%).

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, which dietary choices would the nurse implement?

A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

For the patient with pulmonary hypertension, which diagnostic screening tool would the nurse anticipate while reviewing the findings?

A nitric oxide (NO) challenge A NO challenge is a diagnostic screening tool for pulmonary hypertension and is used to improve oxygenation during mechanical ventilation for this patient population. ECMO is an alternative form of pulmonary support for the patient with severe respiratory failure. Oscillatory ventilation involves delivery of a small tidal volume at rapid respiratory rates to recruit and maintain lung volume and reduce intrapulmonary shunting. Prone positioning improves alveolar expansion.

Which patients are appropriate for the nurse to refer to the burn center? Select all that apply.

A patient with burns of the feet A patient with an inhalation injury An elderly patient with third-degree burns A burn care unit provides advanced care to burn patients to prevent complications and keep the condition from worsening. An inhalation injury increases the risk of airway obstruction and requires a referral to the burn unit. Burns on both feet are associated with complications like contractures, and the patient needs to be referred to the burn care unit. Third-degree burns in any age-group require referral. Burns involving minor joints do not require referral to burn centers; however, burns of major joints require referral. Partial-thickness burns require referral if they involve more than 10% of the body surface area.

In which order do the pathophysiologic changes leading to clinical manifestations of acute respiratory distress syndrome occur?

Acute injury to the alveolar-capillary membrane Damage to type II alveolar cells Decreased surfactant production Decreased alveolar compliance and recoil Atelectasis Following lung injury and damage to the alveolar capillary membrane, inflammatory changes lead to damage to the type II alveolar cells, which are responsible for producing surfactant. As surfactant level decreases, alveoli can no longer maintain stability and collapse, leading to decreased alveolar compliance and recoil, and finally resulting in atelectasis. The nurse will observe increased work of breathing and auscultate lung crackles at this stage.

A patient is admitted to the emergency department following a near-drowning event. Two sets of arterial blood gases (ABGs) were prescribed. The first set was done before oxygen therapy; the second was done after the patient received high-flow oxygenation therapy with continuous positive airway pressure (CPAP) for 30 minutes. The nurse reviews the results and suspects which condition?

Acute respiratory distress syndrome (ARDS) Refractory hypoxemia with increasing oxygenation is a hallmark sign of acute respiratory distress syndrome (ARDS). An indirect cause of ARDS is near-drowning. Acute pneumonia may create a respiratory acidosis but also produces a productive cough. Hypoxemic respiratory failure is defined as a PaO2 less than 60 mm Hg while the patient is receiving inspired O2 concentration of 60% or more. Hypercapnic respiratory failure is a PaCO2 greater than 50 mm Hg with acidemia.

Which intervention would the nurse implement for a patient with sepsis who has a temperature of 101.6°F (38.8°C)?

Administer antipyretics. The nurse should treat the patient's fever with antipyretics and remove the patient's covers or use light sheets. Bathing the patient with warm water will not assist in lowering the patient's core body temperature, and the nurse should decrease the room temperature.

When a patient admitted with respiratory failure has a low central venous pressure (CVP), which action prescribed by the health care provider will the nurse question?

Administer furosemide 20 mg per hour IV. A low CVP indicates hypovolemia, so the nurse will question administration of a diuretic such as furosemide, which would further deplete fluid volume. Administration of normal saline would be appropriate for a patient with a low CVP. IV corticosteroids are commonly prescribed for patients with respiratory failure to decrease inflammation that may compromise airways. Because anxiety may contribute to hypoxemia, benzodiazepines such as lorazepam may be ordered for patients with respiratory failure, although the nurse will carefully monitor respiratory rate when giving any sedative drug.

Which interprofessional action will the nurse take first for a patient who has hypoxemia caused by pneumonia?

Administer oxygen. The initial action in a patient with hypoxemia is administration of supplemental oxygen to improve oxygen saturation to 90% or better. Pneumonia causes ventilation-perfusion (V/Q) mismatch, and other treatments are likely to be needed as well. Antibiotics are prescribed to treat bacterial pneumonia (after blood and sputum cultures are obtained). Coughing helps clear airways and decrease the V/Q mismatch by improving ventilation. Increased fluid intake will help thin respiratory secretions and make them easier to expel.

A burn patient has not received any active tetanus immunization within the previous 12 years. Which is the primary nursing measure to help prevent the development of tetanus in the patient?

Administer tetanus immunoglobulin. Because the patient has not received any active immunization in the past 12 years, tetanus immunoglobulin administration is the primary measure. It would help in preventing the development of tetanus. Tetanus toxoid administration would have been the primary measure if the patient had received active immunization within the past 10 years. Providing 100% oxygen does not ensure aerobic conditions at the burn area. Musculoskeletal relaxants will be helpful only after the patient develops tetanus.

Which actions would the nurse take to safely administer dobutamine to a patient with cardiogenic shock? Select all that apply.

Administer through a central line. Monitor heart rate and BP. Stop infusion if tachydysrhythmias develop. When using dobutamine, the patient's heart rate and BP should be continuously monitored because it may worsen hypotension, requiring the addition of a vasopressor. The infusion should be stopped if tachydysrhythmias develop. The administration through a central line is recommended because infiltration leads to tissue sloughing. The drug should not be administered with sodium bicarbonate because it can get deactivated. Because dobutamine is not adsorbed in plastic containers, it is not necessary to administer the drug in glass bottles.

Which nursing interventions would the nurse perform when administering dopamine to a patient experiencing cardiogenic shock? Select all that apply.

Administer via a central line. Monitor for tachydysrhythmias. Monitor for peripheral vasoconstriction. Dopamine is a positive inotropic agent used in cardiogenic shock. The drug may cause tissue sloughing, if infiltrated. Therefore it is administered through a central line and not via a peripheral line. The patient should be monitored for tachydysrhythmias caused by enhanced inotropic effects. There is also a risk for peripheral vasoconstriction, so the nurse should be observant for symptoms such as paresthesia and coldness of the extremities. The drug may get deactivated by an alkaline solution; therefore it should not be administered along with sodium bicarbonate. Because dopamine is not known to have an adrenergic action, it will not cause pulmonary edema.

When providing care for a critically ill patient receiving mechanical ventilation, which task must the registered nurse (RN) perform and not delegate to the unlicensed assistive personnel (UAP)?

Administering sedatives While caring for a patient requiring mechanical ventilation, the RNs must administer sedatives by themselves; they should not delegate this task to UAP. The RN may delegate the tasks of obtaining vital signs, measuring urine output, and performing bedside glucose tests to the UAP.

A nurse is reviewing the chart of a 68-year-old patient admitted with pneumonia. The nurse knows that the patient has the potential to develop sepsis based on which risk factors?

Age Sepsis is a constellation of symptoms or syndrome in response to an infection. Advanced age, recent surgery, a history of chronic disease, and immunosuppressive therapy like chemotherapy puts a patient at a greater risk for infection. Hearing loss, daily exercise, and daily intake of multivitamins do not increase a patient's risk of infection.

Which medication would the nurse prepare to administer to a patient with septic shock?

Aggressive IV crystalloid fluid resuscitation Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and β-adrenergic blockers are used most often in the treatment of patients in cardiogenic shock.

Which medications will the nurse administer for a patient with wheezing? Select all that apply.

Albuterol Metaproterenol Short-acting bronchodilators, such as albuterol and metaproterenol, reverse bronchospasm. Lorazepam is used to decrease anxiety, agitation, and pain. Nitroglycerin might be used in patients with crackles in the lungs caused by pulmonary edema. Antibiotics such as azithromycin are often given to treat pulmonary infections.

When a patient with an asthma exacerbation develops acute respiratory failure, which prescribed therapy will the nurse administer first?

Albuterol nebulizer treatment Bronchospasm in an asthma exacerbation causes hypoxemia and inhaled albuterol will work rapidly to relieve bronchospasm. Salmeterol is also a bronchodilator but is long-acting and will not work quickly to treat bronchospasm. IV benzodiazepines may sometimes be given in acute respiratory failure but will not relieve the airway narrowing that causes respiratory failure in an acute asthma attack. IV corticosteroids such as methylprednisolone will reduce airway inflammation but may take several hours before effects are noted.

Which patient would the nurse monitor most closely for possible development of sepsis?

An 86-year-old patient with a fever and history of chronic urinary tract infections Advanced age, recent surgery, history of chronic disease, and immunosuppressive therapy put a patient at risk of infection. Due to these factors, the 86-year-old patient with a fever and chronic infections has the highest risk for developing sepsis. The seven-year-old patient only exhibits one risk factor, and the 54-year-old patient does not exhibit any risk factors. The 62-year-old patient has risk factors of advanced age and chronic disease, but the lack of fever puts this patient at a lower risk.

A patient with multiple bee stings has edema on the lips and tongue, chest pain, dizziness, wheezing, and stridor. Which type of shock would the nurse expect to incorporate into the plan of care?

Anaphylactic Anaphylactic shock is an acute, life-threatening hypersensitivity reaction to a sensitizing substance that, in this case, is insect venom. The reaction quickly causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space. The consequences of these pathophysiologic processes include edema on the lips and tongue, chest pain, wheezing, and stridor. Sepsis is a systemic inflammatory response to a documented or suspected infection. Obstructive shock develops when a physical obstruction to blood flow occurs with decreased cardiac output. Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above.

Which prophylactic treatment for stress ulcers would the nurse expect to administer to a patient with multiple organ dysfunction syndrome (MODS)? Select all that apply.

Antacids Proton pump inhibitor Sucralfate The patient with MODS is at risk of developing stress ulcers due to decreased peristalsis and mucosal ischemia. Antacids, sucralfate, and proton pump inhibitors are the appropriate treatment used for stress ulcer prophylaxis. Diuretics are used to treat fluid imbalance and improve renal function. Calcium channel blockers are used to treat cerebral vasospasms.

The nurse assesses a patient with cardiogenic shock and expects which findings? Select all that apply.

Anxiety Tachycardia Decreased UO Weak peripheral pulses The early presentation of a patient with cardiogenic shock is similar to that of a patient with acute decompensated heart failure (HF). The patient may have tachycardia. Signs of peripheral hypoperfusion (e.g., cyanosis, pallor, diaphoresis, weak peripheral pulses, cool and clammy skin, delayed capillary refill) occur. Decreased renal blood flow results in sodium and water retention and decreased urine output. Anxiety, confusion, and agitation may develop with impaired cerebral perfusion. The patient may have hypotension, not hypertension.

Which clinical manifestations would the nurse expect to find when assessing a patient in hypovolemic shock? Select all that apply.

Anxiety Tachycardia Hypotension Decreased capillary refill In a patient with hypovolemic shock due to hemorrhage, assessment findings will be related to intravascular fluid loss that include cool skin, decreased capillary refill, hypotension, orthostatic changes, tachycardia, anxiety, and decreased urine output. Hypothermia is associated with spinal cord injury. Lactate, not lactic acid, is increased.

A patient's partial-thickness burn injuries were debrided and covered with a silver-impregnated dressing a week ago. Today the nurse notes the wounds have been fully debrided. Which would be the nurse's priority intervention for wound care at this time?

Apply fine-meshed petroleum gauze to the debrided areas. When the partial-thickness burn wounds have been fully debrided, a protective, coarse- or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. The nurse would not wash the wound aggressively with saline three times daily, apply cool compresses, or apply a new dressing at this time.

Which diagnostic test will provide the best information about the respiratory status of a patient with chronic obstructive pulmonary disease (COPD) and pneumonia?

Arterial blood gas analysis Arterial blood gas analysis provides information about both oxygenation (oxygen saturation and PaO2) and ventilation (PaCO2), as well as acid-base balance (pH and HCO3), which are all needed in a patient with COPD and pneumonia, who is likely to have abnormalities with both oxygenation and ventilation. Chest x-ray is a commonly used diagnostic test to determine possible causes of respiratory distress or failure but does not give information about the patient's current respiratory status. Pulse oximetry provides information about oxygenation but does not give data about the patient's ventilation or acid-base balance. End-tidal carbon dioxide is used to assess tube placement within the trachea immediately after intubation but does not provide data about oxygenation.

For the patient receiving mechanical ventilation after sustaining a stroke, which data findings determine the patient's ventilator settings?

Arterial blood gases (ABGs), current physiologic state, and respiratory muscle strength Settings on mechanical ventilators are based on the patient's physiologic status, such as ABGs, ideal body weight, current physiologic state, level of consciousness, and respiratory muscle strength. Ethics committee decisions and family preference are psychosocial in nature and are not criteria used to determine mechanical ventilation settings.

Which interventions would the nurse expect to include in the nutritional plan of care for a patient with severe burns who has been intubated? Select all that apply.

Assess bowel sounds every eight hours. Begin early enteral feeding with smaller-bore tubes. Begin the feedings slowly at a rate of 20 to 40 mL/hr. The nurse should assess bowel sounds every eight hours to ensure proper functioning of the bowels before starting oral nutrition. The nurse should also begin early enteral feeding with smaller-bore tubes because this preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. The feedings should begin slowly at a rate of 20 to 40 mL/hr to protect the GI function and gradually increase as the patient improves. Assessing the respiratory rate every two hours is not related to nutritional therapy. Large amounts of feeding within the first six hours may overload the system and affect GI function.

Which action will the nurse take when caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving continuous lateral rotation therapy (CLRT) while on mechanical ventilation?

Assess skin condition frequently to detect skin breakdown. Since hypoperfusion of skin can occur with ARDS, monitoring of the skin is important even when patients are receiving CLRT. Prone positioning may be used in patients with ARDS, but is not a part of CLRT, which turns patients laterally from side to side. Pillows and blankets can be used for comfort and to minimize pressure on the skin with CLRT. Enteral feedings may be given with CLRT.

Which actions will the nurse include in the plan of care for a patient with respiratory failure caused by an exacerbation of chronic obstructive pulmonary disease (COPD)? Select all that apply.

Assist patient with use of albuterol nebulizer. Offer fluids at frequent intervals. Titrate oxygen to keep O2 saturation at 90%. Teach patient how to perform huff coughing. Because a patient with COPD will have difficulty clearing thick secretions, offering fluids at frequent intervals and huff coughing are used to help to clear the airways. Short acting bronchodilators are used to decreased bronchospasm and improve ventilation. Oxygen administration is adjusted to keep the oxygen saturation in the low normal range, which will avoid respiratory depression. The head of the bed will be elevated in order to maximize respiratory expansion. Pharyngeal suctioning is used only if the patient is unable to clear respiratory secretions by coughing and is not scheduled every two hours.

Which action will the nurse take to prevent respiratory failure when caring for an obese patient?

Assist the patient to ambulate frequently. Abdominal distension in obese patients restricts lung expansion and increases the risk for respiratory failure. Being in an upright position and ambulating will improve lung expansion and gas exchange. Oxygen administration will be used to treat respiratory failure if the patient becomes hypoxemic but is not a preventative measure. Bronchodilators will not be helpful in addressing the poor lung expansion that places the patient at risk for respiratory failure. Pursed-lip breathing will not be helpful in preventing respiratory failure due to obesity since obesity leads to poor lung expansion during inspiration and pursed-lip breathing improves the ability to exhale air during the expiratory phase of respiration.

Which action will the nurse take to help a patient to perform staged coughing?

Assist the patient to push a pillow against the diaphragm while coughing. Staged coughing is performed while bending forward with a pillow pressed against the diaphragm. Positioning with the good lung down prior to coughing may help mobilize secretions, but staged coughing is performed with the patient upright. Pushing upward from the base of the lungs is done when assisting the patient with augmented or "quad" coughing. The tripod position is helpful in expanding the lungs, but staged coughing requires the use of the patient's arms and hands to augment diaphragmatic contraction when coughing.

When arterial blood gases for a patient with respiratory failure who is receiving bilevel positive airway pressure (BiPAP) indicate a PaO2 of 48 mm Hg, which interprofessional action will the nurse anticipate?

Assisting with endotracheal intubation Because the patient's PaO2 indicates hypoxemic respiratory failure even with the use of noninvasive positive pressure ventilation, endotracheal intubation and mechanical ventilation will be needed. The respiratory rate for BiPAP is determined by the patient's spontaneous breathing rate; increasing the BiPAP rate is not an option. Although a patient who is intubated and mechanically ventilated may be placed in the prone position, BiPAP cannot be used in a prone patient. Since BiPAP uses positive pressure to increase ventilation depth and alveolar ventilation, encouraging the patient to take deep breaths will not improve oxygenation.

For the intubated patient, which length of time would the nurse allow for the patient's spontaneous breathing trial (SBT) to last?

At least 30 minutes but not more than 120 minutes Patients who demonstrate weaning readiness have an SBT. An SBT should be at least 30 minutes but no more than 120 minutes. At least 15 minutes but no more than 30 minutes, at least 30 minutes but no more than 60 minutes, and at least 60 minutes but no more than 120 minutes are not the recommended timeframes to determine weaning readiness.

The nurse notes an increase in the depth and rate of the respirations of a patient with septic shock. The nurse suspects which causative factor for the change in the patient's respiratory effort?

Attempt to correct metabolic acidosis For a patient experiencing septic shock, the respiratory changes in the depth and rate occur as a result of the body's attempt to correct metabolic acidosis. A loss of blood is associated with hemorrhagic shock. The described changes in the respiratory system do not specifically occur as a result of pain. A patient with a fluid overload will have abnormal lung sounds, rapid shallow breathing, and shortness of breath.

Which action will the nurse take to improve oxygenation in a patient with left-sided pneumonia?

Augmented coughing or huff coughing Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. Since respiratory secretions are usually thick and viscous in pneumonia, fluid intake of at least 2000 to 3000 mL daily is encouraged. A patient with left-sided pneumonia would be positioned on the right side to maximize perfusion to the good lung and improve gas exchange. Nutrition is important in patients with pneumonia, but there is no indication that the patient requires a nasogastric tube for feeding.

Which actions will the nurse take when administering an albuterol inhaler to a patient with respiratory failure? Select all that apply.

Auscultate lungs before and after inhaler use. Check heart rate before and after inhaler use The nurse will listen to breath sounds before and after inhaler to evaluate whether the inhaler has been effective in dilating the airways. Albuterol may cause tachycardia and other dysrhythmias, so the nurse will check the heart rate before and after albuterol inhaler use. A spacer is recommended with albuterol inhaler use to improve the effectiveness of the medication. While heart rate and BP should be monitored, it is not necessary to check temperature before administration of an albuterol inhaler. Albuterol is rapidly acting, and improvement is expected within a few minutes after inhaler use.

Which nursing interventions would be utilized in patients with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), specific to the hematologic dysfunction commonly experienced by patients? Select all that apply.

Avoiding multiple venipunctures Minimizing IM injections Platelet count is decreased in patients with SIRS and MODS with hematologic dysfunction. This decrease increases the risk for bleeding. Therefore multiple venipunctures should be avoided, and IM injections should be minimized to decrease traumatic interventions. Continuous infusion of insulin and glucose may be needed to maintain blood glucose levels in cases in which there is endocrine dysfunction rather than hematologic dysfunction. Continuous echocardiographic monitoring helps to manage cardiovascular dysfunctions rather than hematologic dysfunctions. Positive end-expiratory pressure ventilation helps to manage respiratory dysfunction associated with SIRS and MODS.

Which medication helps to treat infection in a patient with acute respiratory failure?

Azithromycin Antibiotics like azithromycin help to prevent infections. Propofol is a sedative and analgesic drug mainly administered to mechanically ventilated patients in respiratory failure. Albuterol is a bronchodilator that reduces bronchospasm and helps to promote alveolar ventilation. Fentanyl is an opioid used to decrease pain and anxiety.

Which type of organism most commonly causes sepsis?

Bacteria The most common organisms that cause sepsis are gram-negative and gram-positive bacteria. Fungi, viruses, and parasites can also cause sepsis, but not as frequently.

Which complication will the nurse monitor for when caring for a patient receiving mechanical ventilation with high levels of positive end-expiratory pressure (PEEP)?

Barotrauma A high level of PEEP leads to barotrauma due to the overdistention and rupture of alveoli. Oxygen toxicity may occur when a patient receives high oxygen concentrations for prolonged periods but is not a complication of PEEP. Pneumothorax may occur with PEEP, but pneumoperitoneum is not a complication of positive pressure ventilation or PEEP. Oversedation may occur with excessive use of sedative medications but is not a complication of PEEP.

Which respiratory complications will the nurse assess for when caring for a patient with acute respiratory distress syndrome who requires mechanical ventilation with positive end-expiratory pressure (PEEP)? Select all that apply.

Barotrauma Pneumothorax Decreased cardiac output Ventilator-associated pneumonia Positive pressure ventilation (PPV), especially with PEEP, can overdistend alveoli and cause barotrauma, alveolar rupture, and pneumothorax. Cardiac output can decrease as the increased intrathoracic pressure leads to decreased venous return and preload reduction. Ventilator-associated pneumonia is a possible complication as endotracheal intubation or tracheostomy increases aspiration risk. Pulmonary hemorrhage is not a common complication since the pulmonary capillaries are not damaged by PPV or PEEP.

The nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. The nurse monitors for which complications? Select all that apply.

Barotrauma Stress ulcers Acute kidney injury Venous thromboembolism (VTE) Ventilator-associated pneumonia Complications of ARDS are many and develop because of the condition itself or its treatment. These complications include barotrauma, stress ulcers, acute kidney injury, venous thromboembolism, and ventilator-associated pneumonia. Barotrauma occurs when alveoli are overdistended during mechanical ventilation. In ARDS, blood is diverted from the gastrointestinal (GI) system to the lungs in an effort to increase body oxygenation, thereby producing stress ulcers. Decreased renal perfusion and decreased oxygen delivery to the kidneys in ARDS often results in acute kidney injury. ARDS puts patients at risk for venous stasis and immobility resulting in venous thromboembolism. Finally, ventilator-associated pneumonia occurs for many reasons, including prolonged mechanical ventilation, impaired host defense, and aspiration of gastric contents. CHF is not a complication associated with mechanical ventilation.

Which assessment findings are the earliest indicators of hypoxemic respiratory failure? Select all that apply.

Because the brain is very sensitive to changes in oxygen level, restlessness, confusion, and agitation are early indications of hypoxemia. Cyanosis is a late sign and does not occur until hypoxemia is severe. Lethargy is a clinical manifestation of hypercapnic respiratory failure and is seen with a high carbon dioxide level. High carbon dioxide levels seen in hypercapnic (ventilatory) respiratory failure also cause headache because of dilation of the blood vessels in the brain and increase in intracranial pressure.

Which intervention would the nurse incorporate into the plan of care for a patient in hypovolemic shock who is becoming anxious and whose urine output is decreasing?

Begin crystalloid fluid replacement. When the volume of blood loss is less than 30%, crystalloid fluid replacements are performed to reverse tissue dysfunction. Blood products are administered when the blood volume loss is more than 30%. The nurse should not wait for deterioration to occur to start fluid replacement therapy. This is because the body can typically compensate naturally for a blood volume loss up to 15%.

The nurse suspects that a patient with septic shock has developed acute respiratory distress syndrome (ARDS). Which intervention is the nurse's priority?

Begin pulmonary management with mechanical ventilation. Patients with ARDS need aggressive pulmonary management with mechanical ventilation. Repeating chest radiograph may be done after initiation of mechanical ventilation. Arterial blood gas measures respiratory alkalosis in early stages of septic shock and metabolic acidosis in late stages of septic shock. Broad-spectrum antibiotics are important in the early component of therapy and should be started within the first hour of severe sepsis or septic shock, but once breathing is compromised, that becomes the priority.

Which laboratory finding indicates persistent hypermetabolism is occurring in a patient who has developed multiple organ dysfunction syndrome (MODS)?

Blood glucose of 65 mg/dL Normal blood glucose ranges from 70 to 100 mg/dL. Persistent hypermetabolism leads to an inability of the liver to convert lactate to glucose and lactate accumulates. Ultimately, the liver is unable to maintain adequate glucose levels, resulting in hypoglycemia. BUN/creatinine ratio would indicate renal involvement. AST and alanine transaminase (ALT) reflect hepatic involvement. Urine-specific gravity reflects renal involvement.

Which conditions can cause hypovolemic shock? Select all that apply.

Bowel obstruction Ruptured spleen Diabetes insipidus Hypovolemic shock may be caused due to bowel obstruction, a ruptured spleen, or diabetes insipidus. Bowel obstruction causes relative hypovolemia by preventing fluid absorption for the bowel. A ruptured spleen may cause massive internal bleeding, leading to hypovolemia. Diabetes insipidus causes a marked increase in fluid loss through the kidneys, leading to hypovolemia. A tension pneumothorax and valvular stenosis may lead to cardiogenic shock.

The nurse assesses a patient and suspects a diagnosis of neurogenic shock based on which findings? Select all that apply.

Bradycardia Hypotension Unstable temperature Signs of neurogenic shock include bradycardia, hypotension, and temperature instability. Dyspnea and weak pulses are not signs associated with neurogenic shock.

Before administering prescribed oxygen therapy via face mask, the nurse would assess whether the patient has a history of which problem?

Claustrophobia Face masks may cause anxiety in the patient with claustrophobia, worsening the symptoms of respiratory distress. Hyperglycemia is not a contraindication to or complication of face mask use. Deviated septum may make a nasal cannula uncomfortable but would not affect the use of a face mask. Addison's disease will not affect the use of a face mask, although prescribed corticosteroid dose may be affected by Addison's disease.

Which clinical manifestations would the nurse observe in a patient during the emergent phase of a burn injury? Select all that apply.

During the emergent phase of a burn injury, the patient exhibits tachycardia and hypotension. Other clinical manifestations during this phase include a loss of appetite, a decreased urine output, and tachypnea.

The nurse provides care for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. After reviewing the patient's medical record, the nurse determines that which assessment is the most important?

Cardiac output Twenty cm of positive end-expiratory pressure (PEEP) is considered to be a high level. As the PEEP level increases, the venous return to the heart, and BP and cardiac output (CO) decrease. As the CO decreases, perfusion to vital organs also decreases, causing damage to vital organs and the brain. It is most important for the nurse to assess the patient's cardiac output because dangerous drops can occur with high levels of PEEP. Assessing for anxiety, assessing the patient's peripheral pulses, and evaluating if abdominal rigidity is present should also be performed, but the priority is assessing cardiac output.

Which factors that directly affect oxygen delivery would the nurse monitor for in a patient with septic shock? Select all that apply.

Cardiac output Available hemoglobin Arterial oxygen saturation Oxygen delivery depends on cardiac output, available hemoglobin, and arterial oxygen saturation (SaO2). The amount of blood that the heart pumps to the body may decide the amount of oxygen delivered to the tissues. Hemoglobin, the protein content in red blood cells, is responsible for carrying oxygen molecules. Low hemoglobin means a low oxygen supply to the tissues. Arterial oxygen saturation indicates the total oxygen carried by the blood in the arteries and implies the level of tissue oxygenation. The urine output and white blood cells are also important parameters to be monitored in a patient who suffers from a shock. However, these do not impact the oxygen delivery directly.

Which condition places a patient at risk for obstructive shock?

Cardiac tamponade Obstructive shock develops when a physical obstruction to blood flow occurs with a decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression (e.g., cardiac tamponade, tension pneumothorax, superior vena cava syndrome). Septic shock occurs as a result of an infection such as pneumonia. A severe burn can result in fluid loss, causing hypovolemic shock. Anaphylactic shock can result from hypersensitivity to a vaccine.

Which conditions could be the possible causes of obstructive shock? Select all that apply.

Cardiac tamponade Tension pneumothorax Superior vena cava syndrome Obstructive shock develops when a physical obstruction to blood flow occurs resulting in decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression caused by cardiac tamponade, tension pneumothorax, or superior vena cava syndrome. Spinal cord injury may lead to neurogenic shock. Hypersensitivity to antibiotics may cause anaphylactic shock.

A patient in a state of shock, is found to be cyanotic and has crackles noted upon auscultation of the lungs. Which type of shock would the nurse expect to incorporate into the patient's plan of care?

Cardiogenic A patient with cardiogenic shock shows peripheral hypoperfusion presenting as cyanosis and has crackles on auscultation of the lungs due to pulmonary congestion. In neurogenic shock, the patient demonstrates symptoms related to the injury such as hypotension and bradycardia. The patient in hypovolemic shock may experience tachycardia as a late sign. In anaphylactic shock, the patient may experience wheezing and stridor.

Which type of shock is associated with hyperglycemia, the presence of pulmonary infiltrates in a chest x-ray, and increased levels of blood urea nitrogen (BUN)?

Cardiogenic Increased blood levels of glucose, nitrogen, and cardiac markers, and the presence of pulmonary infiltrates are seen in cardiogenic shock. Increased blood levels of lactate, glucose, and positive blood cultures are signs of septic shock. Manifestations of obstructive shock are specific to the area or organ of obstruction. Electrolyte imbalances and decreased hemoglobin and hematocrit are seen in hypovolemic shock.

A patient is suspected to have a smoke inhalation burn and carboxyhemoglobinemia. In which order would the nurse perform the treatment interventions?

Check for a patent airway and soot around the nares and tongue. Check for the adequacy of ventilation. Check the patient's pulse. Elevate any burned limbs above the heart to decrease pain and swelling. The most important intervention is to check that the airway is patent. Then evaluate the adequacy of appropriate ventilation, followed by a check of the patient's pulse. Finally, elevate any burned limbs above the heart to decrease pain and swelling.

Which pathophysiologic process results in surfactant dysfunction during the injury phase of acute respiratory distress syndrome (ARDS)?

Damage to alveolar type I and II cells During the injury phase of acute respiratory distress syndrome (ARDS), the alveolar type I and II cells (which produce surfactant) will be damaged. Along with accumulation of fluid and proteins, this cell damage results in surfactant dysfunction. The hyaline membranes that line the alveoli lead to the decrease in gas exchange capability. Engorgement of the peribronchial and perivascular interstitial space results in interstitial edema. Ventilation to perfusion (V/Q) mismatch results in hypoxemia.

Which nursing interventions are appropriate for providing enteral feeding to a patient who is intubated and has burns of more than 5% of the total body surface area (TBSA)? Select all that apply.

Check gastric residuals frequently. Assess bowel sounds every eight hours Determine whether the nasogastric tube is in place. Increase the feeding to the goal rate within 24 to 48 hours. A patient who is intubated and has suffered burns to more than 5% of the TBSA may need gastric feedings to meet adequate nutritional requirements. Early enteral feeding helps to preserve gastrointestinal function, increase intestinal blood flow, and promote optimal conditions for wound healing. The nurse should check the placement of the nasogastric tube and assess bowel sounds every eight hours. The enteral feedings should be started at 20 to 40 mL/hr and slowly increased to the goal rate within 24 to 48 hours. Gastric residuals should be checked to rule out delayed gastric emptying.

Which action will the nurse take first for a patient who has new onset confusion and agitation?

Check oxygen saturation. Since hypoxemia affects the central nervous system very quickly, confusion and agitation are frequently the initial manifestations of hypoxemia. The nurse's first action will be to check the patient's oxygen saturation. Oxygen administration may be initiated if the oxygen saturation is low. The Rapid Response Team may be notified about the changes in the patient condition, but assessment of oxygen saturation and other parameters is needed first. Benzodiazepines such as midazolam may be appropriate for agitation, but further assessment of patient status is needed first.

Which action will the nurse take first when a patient with respiratory failure becomes agitated and restless?

Check pulse oximetry. Because agitation and restlessness are early manifestations of hypoxemia, the nurse will first check to be sure the oxygen saturation is 90% or higher. Reassurance may be offered, but the nurse should first be sure that the patient is not hypoxemic. Notification of the rapid response team may be needed if the oxygen saturation is low. Benzodiazepines such as midazolam can be administered for anxiety if the oxygen saturation is 90% or higher and the patient's rate and depth of respiration are adequate.

Which complication would the nurse monitor for in a patient who is receiving 0.9% NaCl (normal saline) for shock?

Circulatory overload Circulatory overload occurs due to fluid overload. Continuous infusion of 0.9% NaCl increases the fluid volume in the body and may cause circulatory overload. The patient's vital signs must be checked during transfusion of blood or blood products because they could cause an infection or an allergic reaction. Hypernatremia occurs when the patient is on 1.8%, 3%, and 5% NaCl infusions. Infusion of dextran-40 has a tendency to precipitate allergic reactions and acute renal failure.

A patient is undergoing treatment for partial-thickness burns on the legs. In which order would the nurse perform the given actions as a part of wound care?

Cleanse wounds with soap and water. Debride the loose necrotic tissue. Apply paraffin-based fine-meshed gauze dressing. Protect the skin graft with dressing. The nurse should first cleanse the wounds with soap and water or normal saline-moistened gauze. This is done to gently remove the old antimicrobial agent and any loosened necrotic tissue, scabs, or dried blood. Next, debridement should be carried out to gently remove loose necrotic tissue and make the wound ready for treatment. When partial-thickness burn wounds are fully debrided, a protective, coarse- or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied. This helps to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. If grafting is necessary, protect the skin graft with the same greasy gauze dressings next to the graft. This layer of dressing should be followed by a saline-moistened middle layer and dry gauze outer dressings.

Which intervention would the nurse expect to incorporate into the plan of care for a patient with multiple organ dysfunction syndrome (MODS), renal failure, and signs of hemodynamic instability?

Continuous renal replacement therapy Continuous renal replacement therapy is considered the best intervention for the patient. In patients with renal failure and hemodynamic instability, continuous renal replacement therapy is better tolerated than hemodialysis. Diuretic therapy may be given in patients with prerenal manifestations due to MODS. However, diuretics are not administered in renal failure because they are nephrotoxic and can worsen the acute tubular necrosis, leading to acute kidney injury. Aggressive oxygen therapy is not an intervention for renal failure. It is given to MODS patients with acute respiratory distress syndrome.

In which order would the nurse place the steps of how the systemic inflammatory response syndrome (SIRS) leads to an increase in cardiac output occurs?

Correct1.Increase in tissue O2 demands Correct2.Massive dilation of blood vessels Correct3.Decrease in BP and systemic venous return Correct4.Activation of baroreceptor reflex Correct5.Release of inotropic and chronotropic factors SIRS increases tissue oxygen demand, which causes myocardial depression and massive vasodilation. The vasodilation results in a decrease in BP and systemic venous return, which activates the baroreceptor reflex, causing release of inotropic and chronotropic factors. The inotropic factors increase the force of contraction while the chronotropic factors increase the heart rate. The result is an increase in cardiac output.

Which early clinical manifestations of acute respiratory distress syndrome (ARDS) will the nurse monitor for when caring for a patient admitted with sepsis? Select all that apply.

Cough and restlessness Dyspnea and tachypnea Adventitious lung sounds Early clinical manifestations of ARDS usually appear within 24 to 48 hours after a lung injury. The patient may cough, feel restless, and exhibit signs of dyspnea and tachypnea. Chest auscultation reveals adventitious lung sounds that can include crackles and rhonchi. Oliguria caused by acute kidney injury may occur later as a complication of ARDS. Because respiratory rate increases early in ARDS, the patient will initially have respiratory alkalosis. Respiratory acidosis is a later complication as the patient is no longer able to compensate.

The nurse expects which assessment findings in a patient with peritonitis who is experiencing early septic shock? Select all that apply.

Crackles Decreased urine output A heart rate of 120 beats/min The clinical presentation of a patient with early septic shock includes crackles, decreased urine output, and tachycardia. Coma and cool and mottled skin occur with late septic shock.

Which tests would the nurse expect to be ordered for a patient experiencing shock? Select all that apply.

Creatinine Arterial blood gases (ABG) Complete blood count (CBC) Creatinine is a blood test to check kidney function, which is crucial for a patient with shock. Arterial blood gases would be ordered to assess acid-base balance and oxygenation status. A complete blood count would also be ordered to assess red and white blood cell function. PSA is done as a screening for prostate cancer and would not be ordered for a patient experiencing shock. Although a glucose level would need to be checked on a patient in shock, a glycosated hemoglobin assessment, which examines blood glucose control over 12 weeks, would not be ordered for a patient in shock.

Which finding by the nurse who is caring for a patient with acute respiratory distress syndrome (ARDS) is most important to report to the health care provider?

Creatinine 2.8 mg/dL An elevated creatinine level in a patient with ARDS indicates development of acute kidney injury and possible multiple organ dysfunction syndrome (MODS). The nurse will report the creatinine and expect to implement actions such as further diagnostic testing, fluid infusion, and possibly discontinuing medications that might cause kidney damage. Because permissive hypercapnia is a common strategy in ARDS, the PaCO2 does not need to be reported immediately. The hematocrit is slightly low but does not require immediate medical intervention such as transfusion. The oxygen saturation is at the low end of normal, which is acceptable for a patient with ARDS.

Which signs of peripheral hypoperfusion would the nurse expect to see in a patient with cardiogenic shock? Select all that apply.

Cyanosis Weak pulse Cold skin Cyanosis, cold skin, and a weak pulse are the signs of peripheral hypoperfusion in cardiogenic shock. Bradycardia and hypertension are not seen in cardiogenic shock; instead, tachycardia and low BP are noted.

Which treatment would the nurse recognize as appropriate and within the scope of nursing practice when caring for a patient with partial-thickness second-degree burns to the chest, abdomen, and both anterior thighs?

Daily wound cleaning with debridement and sterile dressing changes Daily wound cleansing with debridement and sterile dressing changes is appropriate care for a major burn wound. As a means of promoting healing and preventing infection, wound care and dressing changes are performed once or twice a day with a sterile procedure. The other answer options are not within the scope of nursing practice and may not be appropriate treatment for the burn injury sustained.

A nurse is providing care to a patient with a partial-thickness burn. Which clinical manifestation would the nurse anticipate?

Damage to epidermis and dermis involving varying depths Burns may be superficial or deep thickness. Partial-thickness burns involve damage to the epidermis and dermis at varying depths. Coagulation necrosis, damage to all skin elements, and the destruction of nerve endings are observed in full-thickness burn injuries.

Which findings in a patient with systemic inflammatory response syndrome (SIRS) help the nurse to identify cardiovascular system dysfunction? Select all that apply.

Decrease in BP Decrease in mean arterial pressure Decrease in systemic vascular resistance A patient with SIRS may have cardiovascular system dysfunction manifested as a decrease in BP, mean arterial pressure, and systemic vascular resistance. Heart rate, stroke volume, and cardiac output tend to increase in such patients.

For the patient receiving mechanical ventilation after sustaining a head injury, which neurologic complication would the nurse monitor for potential development in this patient?

Decrease in venous return In a patient with a head injury, positive pressure ventilation decreases the venous return because of the increase in intrathoracic pressure. Increased intrathoracic pressure causes jugular vein distention rather than compression. Positive pressure ventilation increases the cerebral volume. A decrease in venous return causes an increase in intracranial pressure.

Which intervention would the nurse implement to limit auto-positive end-expiratory pressure (PEEP) occurring while the patient receives mechanical ventilatory support?

Decrease the respiratory rates. Auto-PEEP is a result of inadequate exhalation time and may result in increased work of breathing, barotrauma, and hemodynamic instability. Limit the occurrence by decreasing the respiratory rates. Other interventions to limit auto-PEEP include the use of bronchodilators and large-diameter endotracheal tubes, as well as decreasing inspiratory times.

Which clinical manifestation would the nurse anticipate due to thrombosis in the capillaries of the burned tissue of a patient?

Decreased erythrocyte count Thrombosis in the capillaries of burned tissue results in a loss of circulating erythrocytes (red blood cells). An elevated heart rate and decreased BP are signs of hypovolemic shock, which is caused by a massive shift of fluids out of the blood vessels. Hematocrit is elevated in burn injuries due to the hemoconcentration that results from fluid loss.

Which occurrence causes gut bacteria to move into circulation in patients with systemic inflammatory response syndrome (SIRS)?

Decreased perfusion of gut mucosa Decreased perfusion in the GI tract leads to a breakdown of the normally protective mucosal barrier, which causes the bacterial movement from the GI tract into circulation. To control these bacteria, antibiotics are administered. Antibiotics are nephrotoxic medicines that can cause acute kidney injury. The breakdown of the mucosal barrier is the direct effect of hypoperfusion rather than the inflammatory mediators. In critical illnesses, GI motility is often decreased, causing abdominal distention and paralytic ileus.

A nurse notes decreased reflexes during the physical assessment of a patient who was admitted with a burn injury. Which is the likely cause for this clinical manifestation?

Decreased potassium levels A decreased level of potassium, known as hypokalemia, results from the loss of potassium from the burn wounds. Clinical manifestations include muscle weakness, leg cramps, paresthesias, and decreased reflexes. Decreased levels of water and increased levels of sodium do not affect reflexes in patients with burn injuries. Increased sodium levels result in thirst, a dry and furry tongue, lethargy, and seizures.

Which physiologic change is associated with absolute hypovolemia?

Decreased venous return A decrease in venous return is a physiologic change associated with absolute hypovolemia. Third spacing occurs in relative hypovolemia. The preload, not afterload, and cardiac output are decreased.

Which clinical manifestations of acute respiratory distress syndrome (ARDS) are caused by increased pulmonary capillary permeability during the initial phase of ARDS? Select all that apply.

Decreasing oxygen saturation Crackles Intercostal retractions An increase in pulmonary capillary permeability results in fluid movement from the pulmonary capillaries into the interstitial space and alveoli, causing crackles with breathing. Fluid within the alveoli and interstitium also decreases oxygen saturation between the alveoli and pulmonary capillaries, leading to hypoxemia. Interstitial fluid also makes the lungs stiffer and less compliant, increasing the work of breathing and causing labored respirations with intercostal retractions. Tracheal deviation occurs with tension pneumothorax and is not a symptom of ARDS. The lungs have infiltrates with ARDS and will be dull to percussion.

The nurse notes a bright-red area with blisters that blanches with the application of pressure on a burn patient. The patient reports severe pain when the burn is exposed to air. Which type of burn is present?

Deep partial-thickness burn A bright-red area with blisters, blanching upon pressure, and severe pain in the patient indicates a deep partial-thickness burn. Superficial and superficial partial-thickness burns are characterized by erythema, but no blisters, with pain and mild swelling. Full-thickness burns are characterized by dry, waxy, leathery skin that is insensitive to pain due to nerve destruction.

Which process causes hypercapnic respiratory failure in a patient who arrives in the emergency department after an overdose of opioids?

Depressed central nervous system response to carbon dioxide Central nervous system depressants, such as opioids, decrease the carbon dioxide (CO2) reactivity in the brainstem, leading to decreased respiratory rate and depth. Decreased ability to expand the lungs, such as in a patient with rib fractures, causes hypercapnic respiratory failure due to decreased ability to "blow off" carbon dioxide. Trapping of carbon dioxide in the airways leads to hypercapnic respiratory failure in patients with chronic obstructive pulmonary disease or asthma. Damage to the nerve supply to the diaphragm or intercostal muscles may lead to hypercapnic respiratory failure in patients with cervical spinal cord injury or diseases such as Gillian-Barré syndrome.

When using dextran as a fluid therapy for a patient who is in a state of shock, which factors would the nurse consider? Select all that apply.

Dextran as a fluid therapy increases the risk of bleeding. Use in limited quantities for shock therapy because it has side effects. Monitor for allergic reactions. It is important to monitor the patient for allergic reactions and acute renal failure because dextran is often associated with side effects and allergic reactions. The use of dextran as a fluid therapy increases the risk of bleeding, and, therefore, it has limited use in shock therapy. Dextran is a hyperosmotic glucose polymer, and it does not increase the oxygen-carrying capability of blood or help to control bleeding caused by thrombocytopenia.

Which intervention would the nurse implement when providing care for a patient diagnosed with an exacerbation of his or her chronic pulmonary disease?

Discuss mechanical ventilation with the patient, family, and health care providers. The nurse should encourage all patients with chronic illnesses to discuss the possibility of mechanical ventilation with their families and health care providers. The patient may or may not become critically ill without ventilator support. The decision to use, withhold, or withdraw mechanical ventilation requires carefully consideration, as well as respecting the wishes of the patient and caregiver; however, if disagreements occur, the agency's ethics committee may be consulted for assistance.

When caring for a patient with burns to the back, the nurse recognizes that the patient is moving out of the emergent phase of burn injury when which occurs?

Diuresis occurs and hematocrit decreases In the emergent phase, the immediate, life-threatening problems from the burn—hypovolemic shock and edema—are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially, potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize. Changes in arterial blood gases do not readily identify stage of burn injury.

A nurse is instructing a patient about the immediate steps that need to be taken in the case of electrical burns. Which precautions would the nurse instruct as necessary to perform? Select all that apply.

Do not cover the burned part with ice. Do not immerse the burned part in cool water. Cool large burns for not more than 10 minutes. The burned body part of a person suffering from an electrical injury should not be covered with ice because it can cause hypothermia and vasoconstriction and can significantly reduce the blood flow to the affected area. Do not immerse the burned part in cold water because it may cause extensive heat loss. Cooling burns for more than 10 minutes can cause hypothermia. Applying ice to the burned part can cause hypothermia. Burned clothes can be removed gently to avoid further tissue damage; however, clothes that are adhered to the body should not be removed.

Which considerations would the nurse recall when administering vasopressin to a patient with septic shock? Select all that apply.

Do not titrate. Infuse at low doses. Use in vasopressor-refractory patients. Vasopressin should be infused in low doses without titrating it because titration can cause dose-related adverse effects. Vasopressin is usually used for patients who are vasopressor-refractory in order to replace the stores of physiologic vasopressin that are often depleted in septic shock. Inotropic agents can be added with vasopressin to increase tissue perfusion. Vasopressin can be given to patients suffering from coronary artery diseases, but it should be used with caution.

The nurse would recognize which as clinical manifestations of a lower airway lung injury associated with burns? Select all that apply.

Dyspnea Wheezing Altered mental status Dyspnea, wheezing, and an altered mental status are manifestations of a lower airway lung injury associated with burns. Edema and blisters are manifestations of an upper airway lung injury associated with burns.

To which areas would the nurse attach a pulse oximetry probe to monitor the oxygen saturation on a patient in cardiogenic shock? Select all that apply.

Ear Nose Forehead Pulse oximetry is used to monitor oxygen saturation. The patient in a state of shock has poor peripheral circulation, and a peripheral reading may not be accurate. Therefore the probe should be attached to the ear, nose, or forehead for a reliable measurement. Pulse oximetry readings obtained through the toes and fingers may not be accurate due to compromised peripheral circulation.

The nurse is reviewing the fluid and electrolyte shifts that occur during burn injury. Which of these occur during the emergent stage of a burn injury? Select all that apply.

Edema in nonburned areas (third spacing) Elevated hematocrit caused by hemoconcentration Movement of water and sodium to the interstitial fluid During the emergent phase, sodium and water rapidly shift to the interstitial spaces and remain there until edema formation ceases. The hematocrit is elevated because of hemoconcentration related to fluid loss. Fluid also moves to areas that normally have minimal to no fluid, a phenomenon termed third spacing. Albumin also shifts into the interstitial spaces, contributing to the edema. A potassium shift initially develops because injured cells and hemolyzed red blood cells release potassium into the circulation.

Which occurrences cause acute kidney injury (AKI) in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply.

Effects of inflammatory mediators Decreased perfusion to the kidneys Use of nephrotoxic drugs Antibiotics commonly used to treat gram-negative bacteria are often nephrotoxic. These nephrotoxic drugs are one of the causes of acute kidney injury (AKI). Inflammatory mediators and decreased kidney perfusion are causes of AKI. Decreased urine output and aldosterone-mediated sodium and water reabsorption are manifestations rather than causes of AKI.

A patient with a burn injury is brought to the emergency department, and the nurse notes white, leathery skin, dysrhythmias, and a loss of consciousness. Which type of burn injury would the nurse suspect?

Electrical Electrical burns occur from the intense heat of an electrical current. Electrical burns present with dry and leathery skin, dysrhythmia, and a loss of consciousness. Thermal burns occur due to hot liquids or flames, resulting in skin injuries ranging from superficial to full thickness. Chemical burns cause protein damage and liquefaction. Inhalation injury, which results from breathing hot air or harmful chemicals, causes respiratory tract damage.

Which burn injury would the nurse identify as resulting in tissue anoxia?

Electrical injury Electrical injury causes tissue anoxia due to nerve damage and nerve death. The injury sustained by a thermal burn is dependent on the temperature of the burning agent and the length of exposure. Chemical burns can cause tissue damage, and eyes can be injured if a splash occurs. Smoke and inhalation injury result in hypoxia.

Which actions will the nurse take as part of the ventilator bundle when caring for a patient with acute respiratory failure who requires mechanical ventilation? Select all that apply.

Elevate head of bed to 30-45 degrees. Administer proton pump inhibitors. Give injectable anticoagulant medications. Components of the ventilator bundle recommended in national guidelines for all patients who are mechanically ventilated include keeping the head of the bed elevated, use of proton pump inhibitors to avoid stress ulcers, and use of anticoagulant medications to avoid venous thromboembolism. Although patients are sometimes sedated for comfort, the ventilator bundle suggests decreasing sedation daily to evaluate readiness for extubation. Although the prone position is sometimes used for patients with acute respiratory distress syndrome (ARDS), it is not part of the ventilator bundle suggested for all ventilated patients.

In which order would the nurse place the steps that cause a decrease in preload in patients with systemic inflammatory response syndrome (SIRS)?

In patients with SIRS, there is an increase in capillary permeability caused by endothelial damage. Hence, there is shifting of albumin and fluid from the vascular space. As a result, there is a reduction in venous return, which leads to a decrease in preload.

When a patient in respiratory distress has thick and viscous secretions that are difficult to expel, which actions will the nurse take? Select all that apply.

Encourage oral fluid intake of 2 to 3 L daily. Use a nebulizer to administer aerosolized normal saline. Monitor central venous pressure while infusing prescribed fluids. Adequate fluid intake (2 to 3 L/day) keeps secretions thin and easier to remove. Nebulized normal saline may also be used to thin respiratory secretions. In patients who are unable to take adequate oral fluids, IV fluids may be infused but the nurse will monitor for possible fluid overload through actions such as central venous pressure monitoring. Oxygen may also be given by aerosol mask to thin secretions and facilitate their removal. Elevating the head of the bed will improve lung expansion and facilitate a better cough effort.

Following a direct lung injury, which pathophysiologic process occurs in the first few days as the patient develops acute respiratory distress syndrome (ARDS)?

Engorgement of the peribronchial interstitial space In the injury or exudative phase of ARDS (the first few days), there is an engorgement of the peribronchial interstitial space because of increased permeability of the alveolar-capillary membrane. Destruction of the pulmonary vasculature occurs one or two weeks later during the reparative or proliferative phase. As the pulmonary vasculature is destroyed, the patient develops pulmonary hypertension. Lung scarring with permanently decreased lung compliance occurs in the fibrotic or fibroproliferative phase, two to three weeks after the initial acute lung injury.

A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin would the nurse inspect for damage?

Epidermis and dermis In a second-degree, or partial-thickness burn, both the epidermis and dermis are damaged. A first-degree superficial burn, such as sunburn, involves only the epidermis. A third- or fourth-degree full-thickness burn may involve muscle and bone. A third-degree deep partial- to full-thickness burn may include the epidermis, dermis, and subcutaneous tissue.

Which order would the nurse implement first for a patient showing signs of anaphylactic shock from an insect sting?

Epinephrine 1:1000, 0.5 mg IM The patient experiencing anaphylaxis will have bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. Although administering diphenhydramine, oxygen, normal saline are appropriate, they must be done after an open airway has been established.

Which interventions would the nurse expect to see included in the plan of care for a patient with partial- and full-thickness burns on the lower extremities? Select all that apply.

Escharotomy care Daily cleansing and debridement Application of topical antimicrobial agent IV and oral pain medications Pain control is essential in the care of a patient with a burn injury. Daily cleansing and debridement, as well as the application of an antimicrobial ointment, are expected interventions used to minimize infection and enhance wound healing. An escharotomy (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

Which actions would the nurse perform when caring for a patient who received burns from hydrochloric acid on the hands and face? Select all that apply.

Flush affected area with lots of water. Remove all chemical particles on the skin. Remove all clothing containing the chemical. Remove all chemical particles on the skin to remove the burn-causing agent from the patient's body. Remove all clothing containing the chemical because the burning process continues while the chemical is in contact with the skin. Flush affected areas with copious amounts of water to irrigate the skin from 20 minutes to two hours after chemical exposure to clear off the chemical on or around the affected area. Applying ice to the burned area does not help to wash away the chemical. Washing the burned area with water helps to clean off the chemical.

The release of platelet-activating factors in patients who have sepsis triggers which response?

Formation of microthrombi The release of platelet-activating factors in patients with sepsis triggers the formation of microthrombi, causing obstruction of the microvasculature. Third spacing involves fluid moving out of the vascular space into the extravascular space as a result of hypovolemia. The release of vasoactive mediators in anaphylactic shock causes increased capillary permeability; this does not occur with sepsis. In sepsis, the production of cytokines is increased.

Which explanation would the nurse provide the family when inquiring about the purpose of the train-of-four (TOF) peripheral nerve stimulation test for the patient scheduled for ventilator synchrony while medically paralyzed?

Four stimulating currents attempt to elicit one or two muscle twitches. To evaluate a medically paralyzed patient by using the TOF peripheral nerve stimulation, the nurse delivers four successive stimulating currents to elicit muscle twitches. The number of twitches varies with the neuromuscular blockade, but the goal is usually one or two twitches out of four. Four muscle twitches are more than necessary, and the nurse is not stimulating four areas of the brain.

Which type of burn injury would the nurse identify as occurring on the layers of subcutaneous fat, muscle, or deeper structures?

Full-thickness burn A full-thickness burn is a burn of the layers of subcutaneous fat, muscle, or deeper structures. A superficial partial-thickness burn is a burn of the epidermis layer; a sunburn is a type of superficial partial-thickness burn. A deep partial-thickness burn involves the dermis layer between the epidermis and subcutaneous layers.

Which type of burn injury is depicted in the image?

Full-thickness scald burn A full-thickness scald injury is characterized by redness and edema at the affected site. It is caused by immersion of the body part in hot water. A full-thickness thermal burn appears as dry, leathery eschar with a waxy white, dark-brown, or charred appearance. Electrical burn injuries are characterized by coagulation spots on the contact areas of burns. Chemical burn injuries involve discoloration and damage of injured tissue.

Which drug helps to manage renal manifestations in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

Furosemide Furosemide is a loop diuretic that helps to manage renal manifestations in a patient with SIRS and MODS. Sucralfate is administered for prophylaxis against stress ulcers, which are gastrointestinal manifestations of SIRS and MODS. Omeprazole is a proton pump inhibitor that has the same action. Acetaminophen is an antipyretic drug given as an acute intervention to manage fevers in patients who are in shock.

Which information will the nurse obtain when collecting subjective data about a patient with respiratory failure?

Health history

Which types of foods would the nurse encourage for a patient who sustained a chemical burn on 15% of the total body surface area (TBSA)?

High protein and high carbohydrate The patient with a chemical burn of 15% TBSA should be encouraged to eat a high-protein, high-carbohydrate diet. Foods high in protein and high in carbohydrates are important for tissue regeneration and promote wound healing. The daily estimated caloric needs should be calculated and regularly reassessed according to the patient's changing condition.

Which fluid increases osmotic pressure to provide rapid volume expansion for a patient experiencing hypovolemic shock?

Human serum albumin Human serum albumin is a colloidal fluid that increases osmotic pressure and will provide rapid volume expansion. Lactated Ringer's and 3% sodium chloride are used for initial volume replacement in shock, but they do not provide rapid volume expansion. Fresh frozen plasma is used to replace blood loss and replace coagulation factors.

Which clinical manifestation suggests sepsis?

Hyperglycemia in the absence of diabetes Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis, along with tachypnea and tachycardia, not bradypnea and bradycardia.

The nurse is teaching a student nurse about the mechanisms that can trigger systemic inflammatory response syndrome (SIRS). Which manifestation listed by the student indicates a need for additional instruction?

Hypertension Hypertension is not a mechanism that triggers SIRS. SIRS is a response to a variety of mechanisms, including burns, abscess, and pancreatitis.

Which pulmonary manifestation can be caused by systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

Hypertension SIRS and MODS affect the respiratory system and lead to pulmonary hypertension. Pulmonary edema is caused by fluid accumulation in the air spaces. Pulmonary fibrosis is a respiratory disorder caused by scars in the lung tissues or inhalation of airborne toxins. A pulmonary embolism is caused by blood clots or blockage in the pulmonary arteries.

Which conditions are the result of a hypermetabolic response in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply.

Hypoglycemia Hyperglycemia Glycogenolysis Gluconeogenesis In SIRS and MODS, there is rapid conversion of glucose from glycogen stores and amino acids due to hypermetabolic response. In the progressive stage, despite increases in glycogenolysis and gluconeogenesis, the liver is unable to maintain an adequate glucose level, and the patient develops hypoglycemia. Acute adrenal insufficiency in SIRS and MODS also results in a hypoglycemic state. At the initial stage, there is a release of catecholamines and glucocorticoids, which leads to hyperglycemia and insulin resistance. Due to the hypermetabolic response, glycogenolysis occurs, and glycogen stores are rapidly converted to glucose. Once glycogen is depleted, amino acids are converted to glucose through a process called gluconeogenesis. In SIRS and MODS, there is gluconeogenesis, or conversion of amino acids to glucose, rather than glycolysis, or breakdown of glucose. There is glycogenolysis or conversion of glycogen to glucose rather than glycogenesis, or formation of glycogen.

Which occurrence causes dysrhythmias in patients with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

Hypokalemia due to activities of aldosterone and catecholamines In SIRS and MODS, there are hormonal and metabolic changes and fluid shifts, including the release of aldosterone and catecholamines. Aldosterone increases urinary potassium loss and catecholamines cause potassium to move into the cell, resulting in hypokalemia, which causes dysrhythmias. Dysrhythmias are not associated with an increased lactate level caused by metabolic acidosis. Increased capillary permeability causes tachycardia rather than dysrhythmias. The increase in sodium reabsorption raises the serum osmolality and stimulates the release of the antidiuretic hormone (ADH). Increased sodium is not related to the development of dysrhythmias.

Which electrolyte change is likely in patients with systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS)?

Hypophosphatemia In patients with SIRS and MODS, hypophosphatemia is common. The release of aldosterone increases urinary potassium loss, and catecholamines cause potassium to move into the cells. As a result, hypokalemia rather than hyperkalemia occurs. The release of antidiuretic hormone and aldosterone results in sodium and water retention. Hence, hyponatremia does not occur. Other changes include hypocalcemia rather than hypercalcemia.

Which cardiovascular change is commonly found in patients with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

Hypotension Hypotension is commonly found in patients with SIRS and MODS. It results from vasodilation in response to the increase in tissue demands. Vasodilation, not vasoconstriction, causes a decrease in venous return. In addition, the increase in capillary permeability resulting in a shift of albumin and fluid out of the vascular space also causes a decrease in venous return. As a response to the decrease in venous return and BP, the baroreceptor reflex causes the release of inotropic and chronotropic factors. There is an increase in the force of contraction and heart rate resulting in an increase in cardiac output.

Which complication would the nurse monitor for in a patient with sepsis who received large amounts of fluid resuscitation in the emergency room?

Hypothermia When large amounts of fluid are required, the nurse must assess the patient for two major complications: hypothermia and coagulopathy. Hypokalemia and hyperglycemia must be assessed when patients receive hydrocortisone. Reflex bradycardia and headache are side effects of phenylephrine. Cardiac stimulation and bronchodilation are intentionally induced with the use of epinephrine in anaphylactic shock.

The patient in the early postburn period is being treated for pain. Which medication would the nurse recognize as appropriate for use with this patient?

IV morphine sulfate IV medications are used for burn injuries in the emergent phase to deliver relief rapidly and prevent unpredictable absorption as would occur with the IM route. Tetanus toxoid may be administered, but not for pain. The PO route is not used because gastrointestinal function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery.

The nurse is teaching a community group about immediate actions to be taken in the case of burns to more than 10% of body surface area. Which reason would the nurse provide for avoiding the use of ice on the burned body part? Select all that apply.

Ice can cause hypothermia. Ice can cause vasoconstriction. Ice can reduce blood flow to the burned area. Ice can cause hypothermia, resulting in excessive cooling of the burned part and reduction of blood flow to that area. Ice can also cause vasoconstriction, thus causing the blood vessels supplying the burned area to narrow and supply less blood and oxygen. Applying ice does not prevent further tissue damage; instead, it decreases the blood supply, causing delayed wound healing. Ice does not increase the blood flow to the burned area; rather, it decreases the blood flow as a result of vasoconstriction.

In which order would acute respiratory distress syndrome (ARDS) in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) develop?

In SIRS and MODS, there is a release of inflammatory mediators that cause increased capillary permeability. This causes the fluid to move from pulmonary vasculature into the pulmonary interstitial spaces. The fluid then moves to the alveoli, and alveolar edema develops. Type I pneumocytes and then type II pneumocytes are destroyed. The alveoli collapse, which increases the amount of blood flowing to the lungs that does not participate in gas exchange. Ventilation-perfusion mismatch becomes worse, and the end result is ARDS.

List the order in which the pathophysiologic steps of systemic inflammatory response syndrome (SIRS) eventually lead to multiple organ dysfunction syndrome (MODS)?

In SIRS, when the mediators and protein leak into the interstitial space, the white blood cells begin to digest foreign bodies. The coagulation cascade is then activated, leading to the formation of microemboli, which results in shunting of blood or redistribution of blood flow. Organ perfusion is compromised, leading to the dysfunction of multiple organs.

Which laboratory findings of a patient with systemic inflammatory response syndrome (SIRS) suggest progression to hepatic dysfunction? Select all that apply.

Increase in serum ammonia Decrease in serum transferrin Loss of liver function leads to the accumulation of waste products such as ammonia. Hence, an increase in the serum ammonia level indicates hepatic dysfunction. In patients with SIRS, the plasma transferrin level helps to assess protein synthesis. When hepatic dysfunction occurs, there is a decrease in serum transferrin. In hepatic dysfunction, there is accumulation of bilirubin. A bilirubin level greater than 34 µmol/L suggests hepatic dysfunction. A urine NA+ level of 24 mEq/L indicates acute tubular necrosis or an intrarenal manifestation of renal system dysfunction. It does not indicate hepatic dysfunction. Ventilation-perfusion (V/Q) mismatch suggests development of acute respiratory distress syndrome (ARDS) rather than hepatic dysfunction.

When a patient with acute respiratory distress syndrome who is receiving mechanical positive pressure ventilation has a PaO2/FIO2 (P/F) ratio of 90, which action will the nurse anticipate taking?

Increase ventilator O2 concentration (FIO2) Because the P/F ration indicates extreme hypoxemia, the nurse will expect that the FIO2 will be increased to improve patient oxygenation. The ventilator respiratory rate might be increased if the patient had an elevated PaCO2, but an increase in respiratory rate will not improve oxygenation. Decreasing the tidal volume would increase the PaCO2 but would not improve patient oxygenation. Since PEEP tends to improve oxygen transfer from the alveoli to the pulmonary capillary circulation, an increase in PEEP might be expected for a patient with a P/F ratio less than 100.

Which laboratory findings would the nurse expect to see in a patient who is in the early stages of hypovolemic shock? Select all that apply.

Increased glucose levels Decreased potassium levels Increased sodium levels The patient may have increased glucose levels, increased sodium levels, and decreased potassium levels in the early stages of shock. Glucose levels increase due to the release of liver glycogen stores in response to sympathetic nervous system stimulation and cortisol. Sodium levels increase due to the increased secretion of aldosterone, causing renal retention of sodium. Potassium levels decrease because of the increased secretion of aldosterone, causing the renal excretion of potassium. Metabolic acidosis is a manifestation of late shock; respiratory alkalosis is seen in early shock due to hyperventilation. Increased liver enzymes indicate liver cell destruction in the progressive stage of shock.

When maintaining the head of a patient's bed at 45 degrees during mechanical ventilation, the nurse is attempting to reduce the risk for development of which neurologic disorder?

Increased intracranial pressure (ICP) In patients with head injuries, positive pressure ventilation can impair cerebral blood flow, increasing ICP due to impaired venous return and increased cerebral volume. Guillain-Barré syndrome is a condition in which the immune system attacks the nerves. A TBI is any brain dysfunction caused by outside factors. MS is a condition in which the immune system attacks the myelin sheath of the nerves.

When the nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) exacerbation who requires oxygen administration, which assessment finding is of most concern?

Increased lethargy Increased lethargy can be caused by high levels of CO2 since higher-than-normal PaCO2 levels cause central nervous system depression. Although patients with COPD exacerbation may require high oxygen flow rates if they are hypoxemic, the nurse needs to be aware that respiratory drive is sometimes decreased when oxygen saturations are increased. Rhonchi are an expected finding in a patient with a COPD exacerbation. Since air trapping and CO2 retention occurs in COPD, a PaCO2 slightly higher than normal is an expected finding for this patient. Although the oxygen saturation is in the low-normal range, this is an expected finding for a patient with a COPD exacerbation, and the oxygen saturation indicates adequate blood and tissue oxygenation.

Which pathophysiologic changes would the nurse anticipate while caring for a burn patient? Select all that apply.

Increased viscosity Decreased blood volume Increased vascular permeability In a burn injury, the viscosity of body fluids is increased, the blood volume is reduced, and vascular permeability is increased. Hematocrit and peripheral resistance are increased in burn injuries.

When assessing a patient suffering from inhalation burns on the face and chest, which findings would the nurse anticipate? Select all that apply.

Increasing hoarseness Darkened oral or nasal membranes Productive cough with black sputum Painful swallowing In inhalation burns, either the respiratory tract is exposed to intense fumes or heat, or the patient inhales noxious chemicals or smoke. Increasing hoarseness is seen due to irritation of the upper airway during inhalation and the laryngeal edema caused by inhalation injury. Some other signs include darkened oral or nasal membranes and productive cough with black sputum, which are evident due to charring of the membranes of the respiratory tract. Location of contact points is done in case of electrical burns. In this case, the skin may appear leathery, white, and charred.

Which nursing diagnosis would be the priority for a patient with hypovolemic shock?

Ineffective tissue perfusion The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. Ineffective tissue perfusion supersedes acute pain, impaired tissue integrity, and decreased cardiac output because circulation is a priority. Acute pain may occur but is not a priority at this time. Tissue integrity is not impaired.

A nurse is providing care to a patient who suffered burns to the perineum. Which would the nurse suspect the patient is at risk of developing?

Infection from urine contamination The perineum is the part of the body occupied by urogenital passages and the rectum. A patient with burns to the buttocks or perineum is at an increased risk for infection from urine or feces contamination. A patient with burns to the face and neck is susceptible to infection of the respiratory tract. Burns to the hands and feet put the patient at risk for infection of the vascular and nerve supplies. Infection because of poor blood supply to the cartilage is found in patients with ear and nose burns.

For the intubation of a semiconscious patient, which actions would the nurse perform to ensure a safe intubation? Select all that apply.

Inform the patient that brief restraint will be necessary. Remove dentures and any removable objects from the mouth. Explain the procedure to the patient and the patient's role in the procedure. Removing the dentures of the patient during the process of oral intubation is important because the dentures can obstruct the airway. Inform the patient that brief restraint will be necessary for safety purposes. Always brief the patient about the procedure to avoid any type of resistance during intubation, regardless of cognition levels. Metallic objects on the body do not interfere with the procedure of intubation, and, therefore, do not require removal. Before intubating, an extremely important requirement is to preoxygenate the patient with 100% oxygen. This is because the patient will not have an oxygen supply during intubation for a short period.

Which actions will the nurse anticipate taking when the cardiac output decreases in a patient who is being treated for acute respiratory distress syndrome (ARDS) with mechanical ventilation and positive end expiratory pressure (PEEP)? Select all that apply.

Infuse inotropic drugs. Lower the PEEP setting. Administer crystalloid or colloid fluids. Options for treatment of decreased cardiac output in a patient with ARDS who is receiving mechanical ventilation include use of inotropic medications such as dopamine and dobutamine to improve cardiac contractility and fluid or colloid infusions to treat hypovolemia. Since decreased cardiac output secondary to decreased venous return is a complication of PEEP, PEEP level may be decreased when cardiac output drops. Diuretics will lead to volume loss and will likely further decrease in cardiac output. An increase in the FIO2 will not impact on cardiac output.

Which factors would the nurse consider when administering 5% sodium chloride solution for the initial fluid replacement in a patient with hypovolemic shock? Select all that apply.

Infuse the solution through a central line. Monitor the patient closely for signs of hypernatremia. A 5% sodium chloride solution is a hypertonic solution that is used for initial volume expansion in patients with hypovolemic shock. The patient should be monitored for signs of hypernatremia, such as disorientation and convulsions. The infusion should be administered through a central line because it can damage the peripheral veins. The solution does not increase the risk of bleeding and is not photosensitive. Also, it does not increase the risk of renal failure.

When caring for a patient in acute septic shock, which intervention would the nurse expect to incorporate into the plan of care?

Infusing large amounts of IV fluids Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. Diphenhydramine may be used for anaphylactic shock but would not be helpful with septic shock. VADs are useful for cardiogenic shock, not septic shock.

A patient is admitted to the emergency department following a near-drowning event. Two sets of arterial blood gases (ABGs) were prescribed. The first set was done before oxygen therapy; the second was done after the patient received oxygenation therapy with continuous positive airway pressure (CPAP) at 8 L/min for one hour. The nurse reviews the results and expects that which intervention will be prescribed?

Initiate mechanical ventilation. Refractory hypoxemia with increasing oxygenation is a hallmark sign of acute respiratory distress syndrome (ARDS). An indirect cause of ARDS is near-drowning. This patient needs mechanical ventilation to increase oxygenation and decrease carbon dioxide levels. The refractory hypoxemia is the key to what is going on with this patient; obtaining a chest x-ray or repeating ABGs is not the priority. A rate of 8 L/min of O2 is high-level oxygenation. Mechanical ventilation is preferable to increasing the oxygen level again because it will help decrease the patient's work of breathing.

The nurse would evaluate which response to determine the effectiveness of the use of vasopressor in a patient with sepsis?

Mean arterial pressure greater than 65 mm Hg The goal of vasopressor therapy is to maintain a mean arterial pressure greater than 65 mm Hg. Fluids can be increased or vasopressor therapy can be decreased if the patient develops hypotension. Vasopressors do not have an effect on lactic acid results or SpO2.

During which phase of acute respiratory distress syndrome (ARDS) does atelectasis occur due to decreased synthesis of surfactant and inactivation of existing surfactant?

Injury During the injury phase (exudative phase), atelectasis occurs due to decreased synthesis of surfactant and inactivation of existing surfactant. During the proliferative phase, continued inflammation leads to damage to the pulmonary vasculature, fibrosis, and further decreased compliance. The fibrotic phase is characterized by remodeling of the lung with collagenous and fibrous tissues. Refractory hypoxemia is not a stage of ARDS but is first noticed during the injury (exudative) phase as the patient's hypoxemia continues to worsen despite use of high concentrations of oxygen.

In order to accurately measure urine output in a patient with septic shock who is receiving fluid resuscitation, which action would the nurse take?

Insert an indwelling urinary catheter. The nurse will insert an indwelling urinary catheter to measure adequate urine output. Strict input and output and daily weights are not exact enough for measuring urine output. Recording the number of times that a patient goes to the bathroom will not provide a means for measuring the exact urinary output.

Which assessment has priority when the nurse is caring for a patient with Guillain-Barré syndrome?

Inspecting for weak respiratory effort Because Guillain-Barré syndrome causes respiratory failure because of respiratory muscle weakness or paralysis, the priority will be to assess for signs of poor respiratory effort. Orientation and alertness are assessed in all patients but are not affected by Guillain-Barré syndrome and will not contribute to respiratory failure in this patient. Heart rate and BP are not affected by Guillain-Barré syndrome and would not impact on development of respiratory failure. Adventitious breath sounds are not expected in Guillain-Barré syndrome and are not typically a cause of respiratory failure in these patients.

Which advice would the nurse give to the family of an elderly patient to help prevent accidental burns?

Install tap water anti-scald devices. Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people because their skin becomes drier and the dermis thinner. Cooking for the patient may be needed at times of illness or in the future, but there is no indication that the patient needs this assistance. Stopping the patient from smoking may be helpful to prevent burns but may not be possible. Using an open space heater would increase the patient's risk of being burned and would not be encouraged.

A patient with burns needs permanent skin grafting. Which types of grafts would the nurse expect to be considered? Select all that apply.

Integra AlloDerm Autograft Integra is obtained from bovine collagen and glycosaminoglycan bonded to silicone and gives permanent coverage. AlloDerm is obtained from a cellular dermal matrix derived from donated human skin and can be used for permanent grafting. Autograft is from the patient's own skin and can be used for permanent grafting. Homograft is obtained from cadaveric skin and can be used as a temporary graft from three days to two weeks. Heterograft is obtained from porcine skin and can be used as a temporary graft from three days to two weeks.

Which factors would the nurse consider regarding the use of antibiotics for a patient with burns? Select all that apply.

It is essential to check the patient for allergies to sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days. Topical antimicrobial agents may be applied after the wound cleansing. The nurse should assess for a sulfa allergy because some prescribed antibiotics may contain sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days, depending on the patient's clinical situation and the particular product. Topical antimicrobial agents may be applied after the wound cleansing to facilitate healing, and then the affected area should be covered with a light dressing. Systemic antibiotics are not routinely used to control burn wound flora because the burn eschar has little or no blood supply, and consequently, little antibiotic is delivered to the wound. Also, the routine use of systemic antibiotics increases the chance of developing multidrug-resistant organisms. Silver sulfadiazine and mafenide acetate creams are also used as burn antimicrobial creams.

Which benefits does noninvasive positive pressure ventilation (NIPPV) have over other artificial airways? Select all that apply.

It provides ventilatory support without endotracheal intubation. It decreases the need for intubation in patients who are spontaneously breathing. NIPPV provides positive pressure ventilation without the need for endotracheal intubation and decreases the need for intubation in patients who are spontaneously breathing. Respiratory drive is not affected by NIPPV, and patients need to have adequate spontaneous respiratory rate to use this treatment. NIPPV traps secretions in the mask and is not appropriate for patients who have a lot of respiratory secretions. Patients who receive NIPPV may still need to receive bronchodilator therapy because NIPPV does not decrease airway spasm or narrowing.

Which bacteria are often associated with early ventilator-associated pneumonia? Select all that apply.

Klebsiella Escherichia coli Haemophilus influenzae Streptococcus pneumoniae Klebsiella, Escherichia coli, Haemophilus influenzae, and Streptococcus pneumonia are often associated with early ventilator-associated pneumonia. Staphylococcus aureus and Pseudomonas aeruginosa are often associated with late ventilator-associated pneumonia.

Which laboratory value would the nurse monitor to measure the byproduct of anaerobic metabolism in a patient with sepsis?

Lactic acid Lactic acid is the measurement of the byproduct of anaerobic metabolism caused by significant hypoperfusion and impaired oxygen utilization at the cellular level in sepsis patients. Base deficit indicates acid production secondary to hypoxia. Blood cultures are used to determine the organism causing infection. Arterial blood gas measures respiratory alkalosis in early stages of septic shock and metabolic acidosis in late stages of septic shock.

Which signs and symptoms would alert the nurse to the presence of multiple organ dysfunction syndrome (MODS)? Select all that apply.

Lethargy Confusion Pulse of 112 beats/min Respiratory rate of 32 breaths/min BP of 80/60 mm Hg Lethargy and confusion indicates neurologic dysfunction, while tachycardia, tachypnea, and hypotension characterize respiratory and cardiac manifestations of MODS. Wound drainage characterizes signs of an infection, which could be related to the development of MODS but is not diagnostic of MODS.

Which prescribed medication will the nurse administer first for a patient who has just been diagnosed with pneumonia?

Levofloxacin National guidelines indicate that antibiotics should be administered as soon as possible once the patient has a diagnosis of pneumonia because this leads to more rapid recovery. Albuterol would be administered if the patient had symptoms of bronchospasm such as wheezing. Lorazepam would be administered for anxiety that might lead to increased oxygen demand, although the nurse would first assess for any signs of central nervous system depression or respiratory depression. Ibuprofen would assist with pain control and increase patient ability to cough and expel respiratory secretions, but administration of antibiotics has a higher priority to treat bacterial infection.

Which prescribed medications will the nurse anticipate administering for a patient with respiratory failure caused by pneumonia? Select all that apply.

Levofloxacin Methylprednisolone Albuterol Bronchodilators such as albuterol, antibiotics such as levofloxacin, and corticosteroids such as methylprednisolone are used in respiratory failure secondary to pneumonia to open airways, treat infection and decrease airway inflammation. A diuretic such as furosemide would be used for respiratory failure caused by pulmonary congestion due to heart failure but would likely lead to dehydration in a patient with pneumonia. A vasodilator such as nitroglycerin can also be used to decrease pulmonary congestion caused by left-sided heart failure but would not be helpful in treating pneumonia.

An increase in which hepatic parameters would the nurse likely find in the laboratory report of a patient with multiple organ dysfunction syndrome (MODS)? Select all that apply.

Liver enzymes Ammonia (NH3) Bilirubin greater than 2 mg/dL The patient with MODS has compromised hepatic function manifested by increased ammonia, bilirubin levels greater than 2 mg/dL, and increased liver enzymes. Hepatic hypoperfusion and the resultant cell damage may result in decreased serum albumin and transferrin.

Which prescribed medication will the nurse question for a patient who has respiratory failure caused by opioid overdose and aspiration?

Lorazepam Since an opioid overdose causes sedation and decreased respiratory drive, the nurse would question the use of a benzodiazepine such as lorazepam. Albuterol is an appropriate medication for this patient since a bronchodilator will help to open inflamed and narrowed airways. Levofloxacin is appropriate for aspiration pneumonia. Since aspiration will cause bronchial inflammation and narrowing, IV corticosteroids such as methylprednisolone are frequently administered for aspiration pneumonia and respiratory failure.

For the patient with acute respiratory distress syndrome (ARDS) who is being mechanically ventilated, which intervention would the nurse implement immediately upon noting a respiratory therapist's written note indicating a high risk of developing volutrauma?

Make sure the VT is set to 8 mL/kg. The concept of volutrauma in positive pressure ventilation (PPV) relates to lung injury occurring when utilizing a large tidal volume to ventilate noncompliant lungs (i.e., ARDS). A VT between 6 and 10 mL/kg is within normal range. While the patient is on the ventilator, the respiratory therapist's note does not indicate imminent demise. The pressure support is within normal limits at 17 H2O, but patients with ARDS require low-volume ventilation rather than pressure ventilation to protect the lungs. Currently, there is no need to call the health care provider.

A patient with neurogenic shock caused by a spinal cord injury has a PaO2 below 60 mm Hg. Which need would the nurse identify from this finding? Select all that apply.

Mechanical ventilation Higher oxygen concentrations Different mode of oxygen administration Arterial blood gases (ABGs) provide definitive information on ventilation and oxygenation status and acid-base balance. A PaO2 below 60 mm Hg indicates hypoxemia and the need for higher oxygen concentrations or for a different mode of oxygen administration. A rising PaCO2 with a persistently low pH and PaO2 indicate the need for advanced pulmonary management. Most patients in shock are intubated and on mechanical ventilation. Low PaO2 implies the need for ventilation and not fluid resuscitation.

Which acid-base imbalance occurs in multiple organ dysfunction syndrome (MODS) due to impaired tissue perfusion, hypoxia, and increased lactate levels?

Metabolic acidosis Metabolic acidosis occurs due to impaired tissue perfusion, hypoxia, the shift to anaerobic metabolism that increases lactate levels, and renal dysfunction. Respiratory acidosis, respiratory alkalosis, and metabolic alkalosis have different indicators.

Which types of food and drinks would the nurse provide to the patient who is recovering from a full-thickness burn and is in a hypermetabolic state? Select all that apply.

Milkshakes Protein powder High-caloric food A patient with burns needs a high-calorie diet to compensate for the energy loss and increased protein intake to avoid malnutrition and delayed healing. Milkshakes have a lot of calories. Protein powder provides high protein. High-caloric food contains calories in large quantities and will help in the patient's recovery. Tea does not provide adequate quantities of calories and proteins. Low-protein food is not advised for a patient with burns because the demand for protein is high to promote healing and a faster recovery.

Which oxygen-delivery measures would the nurse incorporate into the plan of care for a patient in shock? Select all that apply.

Monitor continuously by using a central venous catheter. Administer supplemental oxygen as prescribed. Space activities that increase oxygen consumption. To optimize oxygen supply and ventilation in a patient suffering from shock, the activities that increase oxygen consumption should be evenly spaced. Mixed venous oxygen saturation should be monitored through a central venous catheter. The patient should not exert energy by excessive moving around because it increases oxygen demand.

Which actions will the nurse take to lower the risk for respiratory failure in a patient who has had rib fractures and head injury during a motor vehicle accident? Select all that apply.

Monitor respiratory rate and depth. Check orientation and alertness frequently. Assist the patient to cough and take deep breaths. Remind patient to use the incentive spirometer frequently. Because the patient has respiratory failure risk factors of rib fractures and head injury, the nurse will monitor respiratory and neurologic status frequently. Coughing, taking deep breaths, and using the incentive spirometer will help improve alveolar ventilation. Bed rest makes it more difficult to take deep breaths and leads to atelectasis, so the nurse will assist the patient to sit up at the bedside and ambulate. Although opioid medications may be used to help control rib pain, they will be used cautiously in a patient with a head injury to avoid respiratory depression and would not be used prophylactically.

When considering the use of nitroglycerin for treating a patient with shock, which actions would the nurse perform? Select all that apply.

Monitor the heart rate. Monitor the BP. Use a glass bottle for infusion. Nitroglycerin is a vasodilator used in the treatment of cardiogenic shock. During medication with nitroglycerin, the patient's heart rate and BP should be continuously monitored in order to prevent any chances of reflex tachycardia. Because plastics tend to adsorb nitroglycerin, glass bottles should be used for infusion to avoid adsorption. Because it is not photosensitive, the drug does not need to be protected from sunlight. The drug can be administered through a peripheral line; a central line is not required.

A nurse working in a burn unit would identify which patients are at an increased risk of developing venous thromboembolism? Select all that apply.

Morbid obesity Prolonged immobility The risk factors for the development of venous thromboembolism in a burn patient are morbid obesity and prolonged immobility. These patients may develop stasis of blood due to immobility, which results in development of venous thromboembolism. Young age is not a risk factor for venous thromboembolism; rather, old age predisposes a person to venous thromboembolism. Usually, lower-extremity burns are risk factors for venous thromboembolism because they cause stagnation of blood. First-degree burn of a finger is not an extensive burn and hence is not a risk factor for venous thromboembolism.

Which prescribed medication will the nurse administer when a patient with respiratory failure caused by pulmonary edema develops tachypnea, agitation, and restlessness?

Morphine sulfate For a patient with acute respiratory failure caused by left heart failure and pulmonary edema, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm in patients with asthma and chronic obstructive pulmonary disease. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation.

The nurse understands that which fluid and electrolyte change occurs during the early emergent phase of burn injury?

Movement of sodium and water into interstitial spaces After the burn, in the emergent phase, the capillary walls become more permeable, causing the movement of sodium, water, and plasma proteins into the interstitial spaces and surrounding tissues. An increased excretion of urine and the return of interstitial fluid to the vascular spaces occur toward the end of the emergent phase. During the early emergent phase, colloidal osmotic pressure is decreased with progressive protein loss from the vascular spaces.

Which medical diagnosis would the nurse suspect as the cause of cardiogenic shock?

Myocardial infarction Myocardial infarction may produce necrotic areas of cardiac tissue that lead to impaired contractility and decreased cardiac output. This may lead to a cardiogenic shock state. Hemorrhage may lead to a hypovolemic shock state, tension pneumothorax may lead to an obstructive shock state, and urosepsis may lead to a septic shock state.

For which complications would the nurse monitor an unconscious patient who suffered an electrical burn? Select all that apply.

Myoglobinuria Cervical spine injury Severe metabolic acidosis Patients with an electrical injury are at risk from myoglobinuria, cervical spine injury, and severe metabolic acidosis. Myoglobinuria occurs because myoglobin from the injured tissue is released into circulation, causing muscle and blood vessel damage. Contact with electrical currents causes muscle contractions, which can fracture the vertebrae and bones. Electrical injury carries the risk of severe metabolic acidosis. Systemic toxicity occurs in patients with chemical burns. Pulmonary edema occurs due to smoke and inhalation injuries.

After receiving mechanical ventilation for several days, which weaning parameter would the nurse utilize to determine whether the patient has enough muscle strength to breathe without assistance?

Negative inspiratory force (NIF) The NIF measures inspiratory muscle strength. Tidal volume and minute ventilation assess the patient's respiratory endurance. Do not utilize forced vital capacity as a measure to determine weaning from a ventilator.

Which type of mechanical ventilation would the nurse associate with an older adult patient's story of using an "iron lung" after contracting polio as a child?

Negative pressure The "iron lung" was the first form of negative pressure ventilation developed during the polio epidemic. Negative pressure uses the chambers encasing the chest and surrounding it with intermittent negative pressure; passive expiration and delivery of the negative pressure was by noninvasive measures. Pressure ventilation means that the peak inspiratory pressure is predetermined and the tidal volume delivered varies based on the patient. Volume ventilation has a predetermined tidal volume delivered with each inspiration and the pressure varies based on the patient. Positive pressure ventilation is the primary method used with acutely ill patients, where air is pushed into the lungs during inspiration under positive pressure.

Which type of shock is associated with bradycardia?

Neurogenic Neurogenic shock is associated with bradycardia. Myocardial dysfunction and changes in body temperature are signs of septic shock. Chest pain is seen in anaphylactic shock. Reduction in preload, capillary refill, and stroke volume are clinical manifestations of hypovolemic shock.

Which finding is the best indicator that a patient with viral pneumonia is developing acute respiratory distress syndrome (ARDS)?

No improvement in O2 saturation with oxygen administration Refractory hypoxemia is the hallmark characteristic of ARDS. Crackles in the lung bases may occur in the early stages of ARDS, but crackles could also be caused by atelectasis or be a symptom of the patient's viral pneumonia. A productive cough is more typical of pneumonia than of ARDS. Intercostal retractions occur with increased work of breathing in ARDS but may also be present with viral pneumonia.

When a patient with pneumonia has worsening oxygen levels while receiving oxygen at 6 L/min by nasal cannula, which interprofessional actions will the nurse anticipate implementing? Select all that apply.

Noninvasive positive pressure ventilation via tight-fitting mask Endotracheal intubation and mechanical positive pressure ventilation Hypoxemia secondary to an intrapulmonary shunt usually requires treatment with positive pressure ventilation and high oxygen concentrations, which help to open airways and increase gas exchange at the alveolar-pulmonary capillary membrane. Both noninvasive positive pressure ventilation (NIPPV) and endotracheal intubation with positive pressure ventilation can be used. Lorazepam administration will decrease respiratory rate and tidal volume, leading to worsening hypoxemia. Since a nasal cannula set at 6 L/minute will deliver an oxygen concentration of 44%, a Venturi mask set to deliver oxygen at 28% concentration will not improve this patient's hypoxemia. Furosemide might be used in a patient with hypoxemia caused by heart failure or pulmonary edema but will not be helpful for a patient with pneumonia.

Which action will the nurse take when a patient with chronic obstructive pulmonary disease (COPD) who was initially experiencing tachycardia, tachypnea, and restlessness becomes lethargic and has a normal respiratory rate?

Notify the health care provider. The onset of lethargy and a lower respiratory rate in this patient suggests respiratory muscle fatigue, increased PaCO2 due to poor ventilation, and risk for respiratory arrest; the nurse will immediately notify the health care provider and prepare for actions such as obtaining arterial blood gases and mechanical ventilation. Although monitoring the patient's status is necessary, monitoring every two hours is not adequate in a patient who is at risk for respiratory arrest. Allowing the patient time to rest will lead to progression of respiratory muscle fatigue and respiratory arrest. Increasing the oxygen flow rate would only be done if the oxygen saturation was low since higher flows of oxygen can sometimes lead to further suppression of respiratory drive in patients with COPD.

Which types of shock are associated with decreased cerebral perfusion? Select all that apply.

Obstructive shock Cardiogenic shock Hypovolemic shock Decreased cerebral perfusion associated with obstructive shock causes anxiety, confusion, and agitation. Manifestations of cardiogenic shock include decreased cerebral perfusion that causes anxiety, confusion, and agitation. Decreased cerebral perfusion associated with hypovolemic shock causes anxiety, confusion, and agitation. Septic shock causes mental changes like confusion, agitation, and coma in the late stages. Loss of reflex activity and flaccid paralysis are seen with neurogenic shock. Anxiety, feeling of impending doom, confusion, decreased level of consciousness, and metallic taste are signs of anaphylactic shock.

A patient in the intensive care unit has been intubated for the relief of airway obstruction. What nursing actions should be performed to prevent complications after intubation? Select all that apply.

Obtain a chest x-ray to confirm the placement. Auscultate lungs bilaterally, and auscultate the epigastrium for breath sounds. Use an end-tidal carbon dioxide detector to note the presence of exhaled carbon dioxide. Following an intubation, it is important to confirm the placement of the endotracheal (ET) tube. Obtain this confirmation by x-ray after visualizing that the ET tube is correctly placed in the trachea. Auscultating lungs bilaterally for breath sounds confirms that air is going into the lungs and not into the stomach. If hearing breath sounds over the epigastrium, the ET tube has gone in the stomach. The presence of carbon dioxide in exhaled air also confirms that the tube has gone into the lungs, and the breathing effort is normal. In this case, a CT scan is redundant. However, an x-ray sufficiently confirms the placement of the ET tube. The patient may require a urinary catheter, but it is not an immediate intervention and is performed after intubation.

Which action by the nurse is appropriate when suspecting an infection in a patient diagnosed with multiple organ dysfunction syndrome (MODS)?

Obtain a prescription for broad-spectrum antibiotic therapy. Obtain a prescription for broad-spectrum antibiotic therapy.

A patient with multiple organ dysfunction syndrome (MODS) has a temperature of 102.2o F and copious amounts of purulent drainage and redness surrounding a diabetic wound. Which action would be the nurse's priority?

Obtain wound and blood cultures. The immediate need when an infection is suspected in a MODS patient is to determine the cause; thus, wound and blood cultures would be the first action. Placing a patient in isolation would not be the priority action. Depending on the cultures, the patient may need to be placed in contact isolation depending on the type of infection. Antibiotics would be started after the cultures are obtained and sent for analysis. The dressing may need to be changed, but this would not be the first action of the nurse.

When assessing a patient receiving mechanical ventilatory support, which clinical manifestations would the nurse associate with ventilator-associated pneumonia? Select all that apply.

Odorous sputum Crackles on auscultation Pulmonary infiltrates on a chest x-ray Odorous sputum, crackles on auscultation, and pulmonary infiltrates noted on a chest x-ray are all clinical manifestations that suggest that the patient has ventilator-associated pneumonia. Hyperthermia (fever), not hypothermia, and elevated white blood cell count are other manifestations of ventilator-associated pneumonia.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation?

One half of the total 24-hour fluid requirement should be administered in the first eight hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first eight hours, one quarter of the total fluid requirement should be administered in the second eight hours, and one quarter of total fluid requirement should be administered in the third eight hours.

Which finding by the nurse is the best indicator that measures to improve oxygenation in a patient on mechanical ventilation for acute respiratory distress syndrome have been effective?

Oxygen saturation 90% to 93% Since oxygen saturations of 90% to 93% are in the low normal range, this is the best indicator that treatment has improved oxygen saturation. Clearing lung sounds may also indicate improvement, but oxygen saturation is a better indicator for improvement in oxygenation. Patient report of improvement in dyspnea is also an indicator of effective treatment, but oxygen saturation in the normal range is a clearer indicator. Heart rate and BP stabilization also occurs with improvement in respiratory status but is not as clear an indicator of improvement in oxygenation as oxygen saturation.

Which finding in a patient with acute respiratory distress syndrome (ARDS) is the best indicator that placing the patient in the prone position has been effective?

Oxygen saturation improves. Prone positioning improves atelectasis and is used for patients with severe ARDS and refractory hypoxemia to improve oxygenation. Secretions may be mobilized in the prone position and lead to a more effective cough, but this is not the major purpose of prone positioning in severe ARDS. Turning the patient to the prone position may help to prevent skin breakdown, but this is not the reason for prone positioning. Breath sounds may improve as alveoli in the posterior part of the lung are able to expand, but the major reason for prone positioning is improvement in hypoxemia.

When the nurse notes difficulty in waking a patient with respiratory failure who also reports a headache, which diagnostic test will be most useful to check?

PaCO2 Decreased level of consciousness and headache are associated with elevation of carbon dioxide levels caused by ventilatory failure. The nurse will check for a possible increase in PaCO2 and will anticipate measures to improve ventilation. PaO2 will be important to check in a patient with clinical manifestations of hypoxemia, such as restlessness and agitation. Pulse oximetry will also be useful to check for hypoxemia in a patient with restlessness or agitation. An electrocardiogram is helpful in determining whether dysrhythmias are occurring because of changes in oxygenation or ventilation but will not be helpful in determining the cause of the patient's headache and lethargy.

When the nurse is assessing a patient with acute respiratory distress syndrome (ARDS), which finding indicates the need to consider lowering the oxygen concentration (FIO2) being delivered by the mechanical ventilator?

PaO2 70 mm Hg on current oxygen setting Because a PaO2 of 60 mm Hg is considered adequate for a patient with ARDS, the nurse will plan to notify the health care provider of the PaO2 of 70 mm Hg and anticipate a decrease in the FIO2 setting. An improvement in breath sounds may indicate improvement in the respiratory status does not provide guidance about the optimal FIO2 for the patient. A PaCO2 of 45 mm Hg is in the normal range and may indicate a need to decrease the ventilator rate or to sedate the patient to prevent hyperventilation since permissive hypercapnia is generally used for treatment of ARDS. Clear mucus may indicate improvement in respiratory status but is not useful in determining optimal FIO2 for the patient with ARDS.

Which finding for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation with positive end-expiratory pressure (PEEP) indicates that current therapies are effective?

PaO2 is greater than or equal to 60 mm Hg. The overall goals in caring for the patient with ARDS are a PaO2 of at least 60mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. A pH of 7.32 indicates acidosis and a need for a change in treatment. The purpose of prone positioning is to improve oxygenation; an unchanged PaO2 with prone positioning indicates that this is an ineffective strategy for this patient. A drop in BP with increased PEEP indicates a decrease in cardiac output and that PEEP may need to be decreased for this patient.

Which finding in patient with possible acute respiratory distress syndrome (ARDS) is most important for the nurse to communicate to the health care provider?

PaO2/FIO2 (P/F) ratio decrease from 300 to 100 Since a P/F ratio change from 300 to 100 indicates severe ARDS, the nurse will rapidly report this change to the health care provider and expect immediate changes in the patient's treatment such as use of noninvasive positive pressure ventilation, intubation, and mechanical ventilation. The elevated heart rate is a compensatory mechanism for hypoxemia but is not as clear an indicator of ARDS. A chest x-ray showing bilateral infiltrates helps to confirm a diagnosis of ARDS but does not necessarily need rapid intervention. Bilateral crackles are a common finding in ARDS but may occur in many other diagnoses that will not require rapid intervention.

The nurse recalls which description as the most accurate regarding a deep partial-thickness burn?

Painful with weeping blisters A deep partial-thickness burn involves the epidermal and dermal layers of the skin. It is characterized by a wet, shiny, weeping surface marked by blisters and is painful and very sensitive to the touch. Necrosis and charring are seen with a full-thickness burn. Redness and pain with minimal damage to the epidermis are characteristics of a superficial, or first-degree, burn.

When examining a patient with septic shock, which symptoms would the nurse expect to find? Select all that apply.

Paralytic ileus Decreased urinary output Gastrointestinal (GI) bleeding Patients suffering from septic shock may experience decreased tissue perfusion, which may result in a paralytic ileus, GI bleeding, and decreased urinary output. Pulsus paradoxus and jugular vein distension are found in obstructive shock and are mainly the result of compromised hemodynamics.

The nurse is caring for a patient who has hypovolemic shock. Which condition would the nurse expect to incorporate into the plan of care?

Severe burns Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. Insect bites may lead to an anaphylactic shock state. Pulmonary embolism may lead to an obstructive shock state, and myocardial infarction may lead to a cardiogenic shock state.

A nurse assesses four patients with burn injuries. Which patient would the nurse suspect of having a first-degree burn?

Patient 1 A first-degree burn is a superficial or partial-thickness burn. It is characterized by redness, pain, and moderate to severe tenderness of the burn site. Therefore the nurse suspects patient 1 to have a first-degree burn. Moist blebs, blisters, and hypersensitivity to touch are observed in a second-degree burn. Third- and fourth-degree burns are full-thickness burns in which there is a lack of blanching on application of pressure.

A nurse is assessing four patients who have sustained respiratory injuries as a result of smoke inhalation. Which patient is exhibiting symptoms of an upper airway injury?

Patient 1 An upper airway injury is a type of smoke or inhalation injury that affects the mouth, oropharynx, or larynx. Stridor is associated with this type of injury; therefore the nurse suspects that patient 1 has an upper airway burn injury. Dyspnea, carbonaceous sputum, facial burns, and signed facial or nasal hairs are observed in patients with lower airway injuries.

Which patient would the nurse suspect may have multiple organ dysfunction syndrome (MODS)?

Patient A MODS requires involvement of at least two organ systems. Patient A has a blood urea nitrogen (BUN)/creatinine ratio greater than 20:1 and a urine specific gravity greater than 1.020, which indicates renal involvement; dyspnea, tachypnea, and a pulmonary arterial wedge pressure (PAWP) less than 18 mm Hg indicate respiratory involvement, thus supporting a potential diagnosis of MODS. Patient B has symptomology indicating involvement of only the hepatic system; the alanine transaminase (ALT) (normal 10 to 40 U/L) and aspartate aminotransferase (AST) (normal 10 to 30 U/L) are both elevated and the patient has jaundice. The urine-specific gravity is less than 1.020 (greater than 1.020 indicates renal hypoperfusion) and BP are within normal limits. Patient C's blood glucose is within normal limits (70 to 120 mg/dL), but urine-specific gravity is elevated, and the urine is dark, indicating possible involvement of only one system (renal). Patient D has a decreased Hct (normal Hct 39% to 50% for males and 35% to 47% for females) and a decreased red blood cell (RBC) count; normal values range from 3.8/4.3 to 5.1/5.7 x 106/μL (male/female) and a decreased Hgb (normal Hgb 13.2 to 17.3 g/dL for males and 11.7 to 15.5 g/dL for females, which may indicate blood loss but does not support a diagnosis of MODS.

Which assessment finding in a patient who reports dyspnea requires the most rapid action by the nurse?

Patient becomes less agitated and is difficult to arouse. When a patient with dyspnea becomes less agitated and more lethargic, it suggests respiratory muscle fatigue and that the patient is unable to continue the increased work of breathing. The nurse will need to take action such as activating the rapid response team and ventilating the patient manually. Three-word dyspnea will be reported to the health care provider and may need actions such as oxygen administration and positioning for maximal lung expansion but does not suggest imminent respiratory arrest. A patient who is able to breathe more comfortably with the head at a 45-degree angle has moderate dyspnea and is not at risk for respiratory arrest. Intercostal retractions suggest increased work of breathing and the nurse will take actions such as elevating the head of the bed, administration of prescribed bronchodilators, and oxygen administration, but does not indicate that the patient may quickly have a respiratory arrest.

Which goal would the nurse use when caring for a patient with systemic inflammatory response syndrome (SIRS) whose bilirubin level is 3 mg/dL?

Patient will maintain adequate tissue perfusion. The nurse will plan to maintain adequate tissue perfusion for a systemic inflammatory response syndrome (SIRS) patient with bilirubin level of 3 mg/dL. An elevation of the bilirubin indicates impaired liver function. Stress ulcer prophylaxis is routine and would have been initiated before SIRS occurred. Abdominal distention and increased intraabdominal pressures are associated with impaired liver function. Monitoring these conditions is essential but is of a lower priority than maintaining tissue perfusion.

When planning for burn management, which patients would the nurse refer to a burn center? Select all that apply.

Patients with hydrochloric acid burns Patients of all ages with third-degree burns Patients with 25% deep partial-thickness burns Patients suffering from hydrochloric acid burns, also known as chemical burns, should be referred to a burn center. Patients of all ages with third-degree burns are severe in condition and should be treated in a burn center. All patients with partial-thickness burns of more than 10% of body surface area should be referred to a burn center because they are severe types of burns and need specialized treatment, care, and isolation. Patients of all ages with first-degree burns can be managed in the hospital and assessed. Patients with 5% superficial partial-thickness burns need not necessarily be referred and can be managed in the hospital.

Which strategies would the nurse implement to reduce the risk for sepsis in a patient who is immunocompromised? Select all that apply.

Pay strict attention to thorough hand washing. Use aseptic technique during invasive procedures. Thoroughly clean or discard equipment between patients. Patients who are immunocompromised are at a high risk for opportunistic infection. Strategies to decrease the risk for infection include paying attention to strict hand washing, using aseptic technique during invasive procedures, and thoroughly cleaning or discarding equipment between patients. Changing the IV site daily increases the risk for infection. Antibiotics are not administered prophylactically.

While planning physical therapy for a patient suffering from burns, which intervention would the nurse include in the plan of care? Select all that apply.

Perform passive and active range of motion (ROM) on all joints. Perform exercises during and after wound cleansing. Perform passive and active ROM on all joints to avoid contractures and prevent compromising the patient's cardiopulmonary status. It is not a good habit to practice physical therapy only occasionally. This is because continuous physical therapy throughout burn recovery is imperative if the patient needs to regain and maintain muscle strength and optimal joint function. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. Performing exercises before wound cleansing is not appropriate. Patients with neck burns should continue to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension and avoid contractures.

Which intervention would the nurse expect to incorporate into the plan of care for a patient receiving ventilation support for multiple organ dysfunction syndrome (MODS) to reduce the chance for respiratory complications?

Place the patient in a continuous-motion bed frame. Continuous lateral rotation therapy via a continuous-motion bed frame is used to increase mobilization and prevent nosocomial infections in the ventilated patient. Turning the patient every two hours can also be helpful, but this is not as effective as continuous lateral rotation therapy. Increasing fluids to 3000 mL may lead to other complications and is not the best choice in this situation. While breathing treatments can also be helpful, continuous lateral rotation therapy is the most effective choice.

Which interventions would the nurse include when developing the plan of care for a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Select all that apply.

Placing the patient under stress ulcer prophylaxis Removing necrotic tissue through aggressive surgery Maintaining strict asepsis of the invasive devices and procedures Assessing the ongoing need for invasive lines and other devices daily In patients with SIRS and MODS, stress ulcer prophylaxis should be in place, especially for those patients who have bleeding risk factors. Removal of necrotic tissue is very important because it can provide a culture medium for microorganisms. Strict asepsis must be maintained when using invasive devices and procedures to decrease the probability of infections. The ongoing need for invasive lines and other devices should be assessed daily to decrease the risk of health care-associated infections (HAIs). Cultures from blood or wound exudates should be obtained before starting a broad-spectrum antibiotic. Antibiotics should not be started if there are signs only suggestive of infection.

Which common complication would the nurse immediately notify the health care provider when a patient who is receiving mechanical ventilation has right-sided breath sounds but no breath sounds on the left side of the chest?

Pneumothorax A result of excessive pressure applied to lung tissue by mechanical ventilation is a pneumothorax. Hypertension is not a direct complication; however, a patient undergoing mechanical ventilation may be anxious and fearful, resulting in high BP; consider sedation in this event. Electrolyte imbalance is not a related complication. Mechanical ventilation does increase intrathoracic pressure, which may then increase cardiac output, causing a beneficial secondary effect.

Which actions will the nurse take to improve oxygenation in a patient who is being treated for respiratory failure due to chronic obstructive pulmonary disease (COPD) and right-sided pneumonia? Select all that apply.

Position the patient on the left side. Avoid administration of prescribed prn morphine. Assist the patient with huff coughing or staged coughing. Titrate oxygen administration to keep pulse oximetry reading at 90%. Positioning the patient with the good lung down will improve ventilation and perfusion to the part of the lung with effective gas exchange and improve oxygenation. An effective cough effort will help clear respiratory secretions and improve ventilation and oxygenation. Oxygen saturation of 90% indicates adequate oxygenation and prevents depression of respiratory drive that can occur in some patients with COPD who receive high oxygen concentrations. Morphine can be helpful in improving respiratory and cough effort in patients with chest pain caused by pneumonia, although the nurse will carefully assess respiratory rate and depth when giving morphine to patients in respiratory failure. Because hydration helps in mobilizing respiratory secretions, patients usually should obtain 2000 to 3000 mL/day of fluids.

Which interprofessional intervention will the nurse anticipate for a patient with intrapulmonary shunt due to acute respiratory distress syndrome (ARDS)?

Positive pressure ventilation Patients with ARDS and intrapulmonary shunting will need positive pressure ventilation, which may initially be given by noninvasive means such as bilevel positive airway pressure (BiPAP) but which usually will require endotracheal intubation and mechanical ventilation. Since intrapulmonary shunting causes hypoxemia, high FIO2 levels may initially be required to treat patients with ARDS. Permissive hypercapnia (PaCO2 higher than 60 mm Hg) may be used in patients with ARDS since tidal volumes are set low to avoid barotrauma (alveolar rupture). Low tidal volumes are used with mechanical ventilation in ARDS to prevent complications such as barotrauma and decreased venous return.

Which mode of ventilation would the nurse suspect, when noting the activation of "auto-positive end-expiratory pressure (PEEP)" during an evaluation of the patient's functioning mechanical ventilator settings?

Pressure mode The auto-PEEP is a pressure mode that provides a pressure-limited breath delivered at a set rate that may permit spontaneous breathing. The PEEP mode is a ventilator maneuver in which the ventilator provides positive pressure to the airway during exhalation. Continuous positive airway pressure (CPAP)is similar to PEEP, but the pressure is delivered continuously during spontaneous breathing, preventing the patient's airway pressure from falling to zero. Volume modes require that rate, tidal volume, inspiratory time, sensitivity, and/or PEEP are set for the patient.

When planning the care of a patient receiving mechanical ventilation, which therapeutic effect would the nurse associate with the prescribed positive end-expiratory pressure (PEEP) setting?

Prevention of alveolar collapse during expiration PEEP is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced FIO2 requirement. PEEP does not cause increased inflation of the lungs or prevent barotrauma. Auto-PEEP resulting from inadequate exhalation time may contribute to barotrauma.

The nurse provides care for a patient experiencing shock. Assessment findings are indicative of decreasing cardiac output and decreased peripheral perfusion. The nurse identifies that the patient is in which stage of shock?

Progressive The cardiovascular system is profoundly affected in the progressive stage of shock. Manifestations of the progressive stage of shock include decreased cardiac output, which leads to decreased BP and increased heart rate (HR). Other manifestations include decreased peripheral perfusion, which leads to ischemia of distal extremities, decreased pulses, and decreased capillary refill. The initial stage of shock is usually not accompanied by clinical changes. During the refractory stage, decreasing coronary blood flow continues to occur, which leads to worsening myocardial depression. During the compensatory phase, coronary arterial dilation occurs, resulting in improved blood flow to the heart.

Which intervention would the nurse implement to prevent development of ventilator-associated pneumonia (VAP) in the intensive care unit?

Promote early exercise and mobility. Guidelines for VAP prevention include early exercise and mobility, minimizing sedation, use of endotracheal tubes with ports for drainage, head of bed at a minimum of 30 to 45 degrees unless medically contraindicated, no routine tubing changes, and strict hand washing before and after suctioning. Draining a ventilator toward the patient places the patient at risk for aspiration and infection.

For the patient with severe acute respiratory distress syndrome (ARDS), which position would the nurse utilize to improve the patient's oxygenation?

Prone Prone positioning is the repositioning of a patient from supine or lateral to on the stomach or face down. This position improves oxygenation by expanding the alveoli. The lateral recumbent (side-lying), lateral (side-lying with knee up), or supine (on the back) positions do not aid in lung expansion to improve oxygenation.

For the patient with acute respiratory distress syndrome (ARDS), which patient position would the nurse utilize to improve lung reexpansion and oxygenation?

Prone Prone positioning refers to the repositioning of a patient from a supine or lateral position to a prone position. This repositioning improves lung reexpansion through various mechanisms. Firstly, when moving the patient from the supine to the prone position, the gravity reverses the effects of fluid in the dependent parts of the lungs. Secondly, in the prone position, the heart rests on the sternum, away from the lungs, contributing to an overall uniformity of pleural pressures. These two mechanisms help in better ventilation in the patient with respiratory failure. The prone position is a relatively safe supportive therapy used for critically ill patients with acute lung injury or ARDS and used for improved oxygenation. Resting in other positions such as sitting, supine, or lateral may not help in oxygenation.

Which actions would the nurse take to safely administer sodium nitroprusside to a patient in cardiogenic shock? Select all that apply.

Protect solution from light. Wrap infusion bottle with opaque covering. Monitor the serum cyanide levels and signs of cyanide toxicity. Sodium nitroprusside is a vasodilator used in cardiogenic shock. The drug tends to release cyanide ions when exposed to sunlight. Therefore, it should be protected from exposure to sunlight by wrapping the infusion bottle with an opaque covering. The patient's serum cyanide levels should be checked, and the patient should be monitored for signs of cyanide toxicity. This includes metabolic acidosis, tachycardia, altered level of consciousness, seizures, coma, and almond smell on the breath. The medication should be reconstituted with D5W only. Monitoring vital signs like body temperature is important but may not directly impact the treatment being administered.

Which nutritional component is most important for a patient with multiple organ dysfunction syndrome (MODS)?

Protein Protein and calorie malnutrition is one of the primary signs of hypermetabolism in MODS. The goal of nutritional support is to preserve organ function by providing early and optimal nutrition. Vitamins, minerals, and carbohydrates may be incorporated into the patient's nutrition plan but are not as helpful as protein and calories.

Which laboratory results indicate involvement of the hematologic system in a patient diagnosed with multiple organ dysfunction syndrome (MODS) after a traumatic injury? Select all that apply.

Prothrombin time (PT) 18 seconds D-Dimer 280 ng/mL Platelets 125 x 103/μL Increased PT, increased D-dimer, and decreased platelets indicate involvement of the hematologic system. Normal PT is 11 to 16 seconds; normal platelets are 150 to 400 x 103/ μL, and normal D-dimer is less than 250 ng/mL. These all indicate involvement of the hematologic system. Normal Hct is 39% to 50% for males and 35% to 47% for females; thus, this result is within normal range. RBC values range from 3.8/4.3 to 5.1/5.7 x 106/μL (male/female); thus, this result is within normal limits.

Which actions by the nurse help to decrease the risk for ventilator-associated pneumonia (VAP) in a patient who is intubated and receiving mechanical ventilation? Select all that apply.

Provide frequent oral care. Elevate head of bed to at least 30 degrees. Assess readiness for extubation daily. Use aseptic technique when suctioning the patient VAP risk is reduced by frequent oral care, keeping the head elevated at 30 degrees to 45 degrees, shorter intubation times, and aseptic technique when suctioning. Although patients on mechanical ventilation frequently require enteral feedings, these increase the risk for aspiration and VAP.

Which intervention would the nurse provide when caring for a patient with a burn injury during the acute phase?

Provide teaching about the physical aspects of recovery. Nurses should provide ongoing support, counseling, and teaching to the patient and the caregiver regarding the physical and emotional aspects of care and recovery. Discussing the need for both home care following discharge and the need for reconstructive surgery occurs during the rehabilitation phase. Beginning fluid replacement occurs in the emergent phase.

A nurse is examining a patient with anaphylactic shock. Which types of skin manifestations would the nurse expect to find? Select all that apply.

Pruritus Flushing Urticaria Insect bites may cause allergic reactions and anaphylactic shock. The skin manifestations may include pruritus, flushing, and urticaria caused by massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. Pallor and cold, clammy skin changes are usually seen in cardiogenic, hypovolemic, and obstructive shock caused by decreased circulatory volume and tissue perfusion.

Which laboratory results would indicate possible development of multiple organ dysfunction syndrome (MODS)? Select all that apply.

Pulmonary artery wedge pressure (PAWP) 15 mm Hg Platelets 100,000 μL Urine-specific gravity 1.042 A PAWP below 18 mm Hg, decreased platelet count (normal 150,000 to 400,000 μL), and increased urine-specific gravity (normal 1.003 to 1.030) are signs of failure in more than one organ system and potential development of MODS. An increased, not decreased, ALT (normal 10 to 40 U/L) and decreased, not increased, SVR (normal 800 to 1200 dynes/sec/cm-5) would be signs of MODS.

When adding the prescribed positive end-expiratory pressure (PEEP) therapy to a patient's mechanical ventilator settings, the nurse would associate the therapy with the development of which complication?

Pulmonary edema Add PEEP therapy to patients with pulmonary edema to provide a counter pressure opposing fluid extravasation. Do not use PEEP for patients with hypovolemia, low cardiac output, or unilateral or nonuniform lung disease because, in those patients, the adverse effects of PEEP may outweigh any benefits.

In which condition will the nurse expect to hear fine and coarse crackles during lung auscultation?

Pulmonary edema Fine and coarse crackles during auscultation are associated with pulmonary edema and caused by opening of small airways and alveoli during inspiration. With pneumothorax, the nurse would anticipate absent breath sounds over the affected lung. Pleural effusion is also associated with diminished or absent breath sounds. Wheezing (due to airway constriction) or diminished breath sounds (ominous sign) would be heard during an asthma exacerbation.

Which findings indicate the development of acute respiratory distress syndrome (ARDS) in a patient with systemic inflammatory response syndrome (SIRS)? Select all that apply.

Pulmonary hypertension Decreased lung compliance Bilateral diffuse infiltrates in the chest In patients with SIRS, the inflammatory mediators leading to pulmonary hypertension directly affect the pulmonary vasculature. The patient with ARDS shows decreased compliance due to the combined effects of pulmonary vasoconstriction and bronchoconstriction. There are bilateral diffuse fluffy infiltrates seen on the chest x-ray. The minute ventilation increases as the patient experiences tachypnea.

When teaching the patient about the use of range of motion (ROM), which explanations would the nurse give to the patient? Select all that apply.

ROM will show the patient that movement still is possible. Active and passive ROM maintain function of body parts. Movement facilitates mobilization of leaked exudates back into the vascular bed. The explanations that should be used are that active and passive ROM maintain the function of body parts and reassure the patient that movement still is possible. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in the interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

Which discharge instructions would the nurse include when teaching a patient with partial-thickness burns on the hands about rehabilitation at home? Select all that apply.

Recommend exercises. Take low-dose antihistamines. Apply water-based creams on healed areas. Protect healed areas from direct sunlight. The nurse should advise the patient to take low-dose antihistamines because these can be used at bedtime if itching persists. The nurse should instruct the patient to protect healed areas from direct sunlight for 3 months to prevent hyperpigmentation and sunburn injury. Only water-based creams that penetrate into the dermis should be used routinely on healed areas to keep the skin supple and well moisturized. This helps to decrease itching and flaking. The nurse should also encourage the patient to perform physical and occupational therapy routines and recommended exercises. The patient may have small, unhealed wounds, and it is therefore important to carry out dressing changes and wound care at home.

When a patient who has been successfully treated for acute respiratory distress syndrome (ARDS) reports anxiety and vivid dreams that interfere with sleep, which action will the nurse take?

Refer the patient for counselling. Survivors of ARDS may have anxiety, depression, poor memory, and posttraumatic stress disorder as long-term complications, and counselling is helpful in identifying and addressing these mental health issues. Since the patient has recovered from ARDS, assessment of oxygen saturation is not needed. There is no data indicating that the patient has diet or exercise habits that are contributing to the symptoms. Since the patient data do not indicate delirium or disorientation, assessment of orientation is not necessary.

Which manifestation in a patient with systemic inflammatory response syndrome (SIRS) suggests respiratory system dysfunction?

Refractory hypoxemia In a patient with SIRS, refractory hypoxemia suggests respiratory system dysfunction. Other manifestations of respiratory system dysfunction include pulmonary hypertension, decreased compliance, and increased minute ventilation.

Which process occurs when the inflammatory response is activated in a patient with systemic inflammatory response syndrome (SIRS)?

Release of mediators A release of mediators occurs when the inflammatory response is activated. Other changes that occur include an increase in metabolism or hypermetabolism, direct damage to the endothelium (not mesothelium), and an increase in vascular permeability.

Which is an initial pathology that causes a significant amount of edema in a patient with septic shock?

Release of proinflammatory cytokines The release of proinflammatory cytokines is an initial pathology that causes an increase in capillary permeability, resulting in a significant amount of edema. Activation of the central nervous system (CNS) and endocrine system is the initial pathology that results in a hypermetabolic state. The formation of microemboli occurs as a result of the release of proinflammatory cytokines and endothelial damage. Impaired cellular metabolism is the end result of the pathophysiologic process in septic shock.

Which pathophysiologic processes occur during the fibrotic phase of acute respiratory distress syndrome (ARDS)? Select all that apply.

Remodeled lung Deceased lung compliance Impairment of gas exchange The fibrotic phase, also known as the chronic or late phase of ARDS, occurs two to three weeks post-lung injury. The lung is completely remodeled by this time with dense and fibrous tissues. The scarring and fibrosis result in the decrease of lung compliance. Impairment in gas exchange is significant because the interstitium is fibrotic in nature. Pulmonary edema occurs in the initial exudative phase of ARDS as the alveolar-pulmonary capillary membrane permeability increases and fluid leaks into the alveoli. Formation of hyaline membranes also occurs in the exudative phase as necrotic cells, proteins, and fibrin line the alveoli, forming membranes that slow gas exchange.

Which action would the nurse take when administering packed red blood cells (RBCs) to a patient in hypovolemic shock?

Replace clotting factors based on laboratory studies. When administering large volumes of packed RBCs, it is important to replace clotting factors to prevent coagulopathy. Because the pack contains only RBCs and not the clotting factors, it should be given extrinsically. Generally, the crystalloid and colloid solutions are warmed before being administered to avoid hypothermia. However, packed RBCs should not be warmed because high temperature can damage the red blood cells. The blood products are almost always cross typed and matched before administration. Antibiotics are not related to the administration of RBCs.

Which organ system is often the first to show signs and symptoms in multiple organ dysfunction syndrome (MODS)?

Respiratory Inflammatory mediators have a direct effect on the pulmonary vasculature, causing increased capillary permeability and eventually movement of fluid into the interstitial spaces of the lungs, eventually causing alveolar edema, often making the respiratory system the first to show signs and symptoms of MODS. While MODS affects the neurologic, cardiovascular, and gastrointestinal systems as well, these systems do not as commonly exhibit manifestations of MODS first.

Which information would the nurse educator include when explaining respiratory failure to new nursing staff members? Select all that apply.

Respiratory failure is categorized as hypoxemic or hypercapnic. Respiratory failure is insufficient oxygen transfer into the blood. Respiratory failure is inadequate carbon dioxide removal from the lungs. Respiratory failure is classified as hypoxemic or hypercapnic. Respiratory failure results when gas exchanging functions are inadequate (i.e., insufficient oxygen is transferred to the blood or inadequate carbon dioxide is removed from the lungs). Although respiratory failure may be secondary to cardiac failure, not all cases of respiratory failure are secondary to cardiac failure and not all heart failure leads to respiratory failure. Respiratory failure is not a disease but a symptom of an underlying pathologic condition affecting lung function, oxygen delivery, cardiac output, or the baseline metabolic state.

Which system shows initial signs of dysfunction in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)?

Respiratory system The pulmonary vasculature is directly affected by inflammatory mediators. Hence the initial signs of dysfunction in SIRS and MODS are seen in the respiratory system. Cardiovascular changes are detected later when there is myocardial depression. Effects on the gastrointestinal system are seen when the motility gets decreased. Central nervous system dysfunctions are seen when the patient's mental status begins to show signs of change.

Which goal for fluid resuscitation would the nurse choose when caring for a patient diagnosed with sepsis?

Restore tissue perfusion. The goal for fluid resuscitation is the restoration of tissue perfusion. Increasing circulating fluid volume is the goal for hypovolemic shock. Restoring blood flow to the myocardium is the goal for cardiogenic shock. Maintaining a mean arterial pressure of 65 mm Hg is the goal when using vasopressors.

In which order would the nurse place the steps of how systemic inflammatory response syndrome (SIRS) causes acute kidney injury?

SIRS causes redistribution or shunting of blood flow, leading to decreased perfusion of the kidney, which activates the SNS and stimulates the renin-angiotensin system. Stimulation of the renin-angiotensin system leads to systemic vasoconstriction. It also causes aldosterone-mediated sodium and water reabsorption, leading to acute kidney injury.

Which interventions would the nurse expect to incorporate into the plan of care for a patient with multiple organ dysfunction syndrome (MODS) to help to decrease oxygen demand? Select all that apply.

Sedate the patient. Administer analgesics. Initiate mechanical ventilation. When managing hypoxemia in a patient with MODS, decreasing the oxygen demand is very important for adequate tissue oxygenation. Sedation, providing analgesia, and mechanical ventilation are helpful in decreasing the oxygen demand of the tissues. Catheterizing the patient may aid in monitoring the urine output but does not help to conserve oxygen. Resting the patient should be preferred over ambulation or movement to limit the intake of oxygen.

For the patient receiving mechanical ventilation, which associated risks would the nurse associate with the prophylactic treatment of a patient with esomeprazole (Nexium) via a gastric tube? Select all that apply.

Sedation Immobility Decreased peristalsis Increased acid production Patients receiving positive pressure ventilation are stressed because of increased acid production, decreased peristalsis, immobility, and sedation. Decreased air swallowing is not a risk requiring prophylactic intervention.

Laboratory tests indicate a burn patient is experiencing hypernatremia. Which clinical manifestations would the nurse monitor? Select all that apply.

Seizures Dried, furry tongue Hypernatremia is an excess amount of sodium in the body, which is seen after successful fluid resuscitation required in the treatment of a significant burn injury. The manifestations of hypernatremia include seizures and a dried, furry tongue. Paresthesia is one of the symptoms of hypokalemia. Tachycardia and muscle cramps are observed in hyponatremia.

A patient who sustained burns develops a paralytic ileus. Which would the nurse suspect to be the cause of this complication?

Sepsis Paralytic ileus is caused when the burn patient experiences sepsis. Enteral feedings may cause the patient to experience diarrhea. Constipation is a side effect for opioid analgesics, which are required for pain management. Curling's ulcer occurs as a result of increased gastric acid secretion.

Which term is used to describe a response to an infection characterized by a dysregulated patient response along with new organ dysfunction?

Sepsis Sepsis is a constellation of symptoms or syndrome in response to an infection. It is characterized by a dysregulated patient response. Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. Inflammation is the body's response to a microorganism entering the body. Organ dysfunction refers to the failure of an organ system in an acutely ill patient in whom homeostasis cannot be maintained without intervention.

A patient with pneumonia develops hypotension, hypothermia, leukocytosis, and hypoxemia. Which type of shock would the nurse infer from these findings?

Septic Septic shock is most commonly found in the patient having gram-negative bacterial infections, such as pneumonia. Because it is characterized by hypotension, hypothermia, leukocytosis, and hypoxemia in patients with infections, the nurse concludes that the patient has septic shock. Neurogenic shock is most commonly seen in the patient who has an injury. Cardiogenic shock is caused by cardiovascular disorders, such as a myocardial infarction and cardiomyopathy. Hypovolemic shock is caused by hemorrhage or trauma.

Vasopressor agents are prescribed for which types of shock? Select all that apply.

Septic Neurogenic Septic shock occurs in response to an infection. It is associated with the release of cytokines and other inflammatory mediators, resulting in vasodilatation, increased capillary permeability, and platelet aggregation. Vasopressors will constrict the blood vessels and relieve hypotension. Neurogenic shock is caused by a severe injury to the central nervous system (CNS), causing a loss of sympathetic stimulation of blood vessels resulting in vasodilatation. A fall in BP can be restored by administering vasopressor agents that act by constricting the blood vessels. Obstructive shock is caused by an obstruction in the vessels of the heart or the heart itself. Restoring the circulation by treating the cause of obstruction will be beneficial for a patient with obstructive shock. Systolic or diastolic dysfunction of the heart results in cardiogenic shock. Treatment involves use of nitrates, inotropes, diuretics, and β-blockers. A loss in the intravascular fluid volume causes hypovolemic shock. Treatment of hypovolemic shock includes restoring the fluid volume by infusion of blood or blood products and crystalloids.

Which types of shock may cause reduced urinary output in a patient? Select all that apply.

Septic Obstructive Cardiogenic Hypovolemic Decreased urine output is a clinical manifestation of septic, hypovolemic, obstructive, and cardiogenic shock. Neurogenic shock is associated with bladder dysfunction. Anaphylactic shock is associated with urinary incontinence.

Which term is used to describe persistent hypotension despite adequate fluid resuscitation requiring vasopressors along with inadequate tissue perfusion resulting in tissue hypoxia?

Septic shock Septic shock is characterized by persistent hypotension despite adequate fluid resuscitation requiring vasopressors along with inadequate tissue perfusion resulting in tissue hypoxia. Sepsis is a constellation of symptoms or a syndrome in response to an infection; it is characterized by a dysregulated patient response. Inflammation is the body's response to a microorganism. Organ dysfunction refers to the failure of an organ system in an acutely ill patient such that homeostasis cannot be maintained without intervention.

Which assessment data would indicate the potential development of multiple organ dysfunction syndrome (MODS)? Select all that apply.

Severe dyspnea Heart rate of 110 beats/min BP of 86/42 mm Hg Respiratory rate of 32 breaths/min Severe dyspnea, tachycardia, tachypnea, and hypotension indicate involvement of two organ systems, supporting a potential diagnosis of MODS. The urine sodium is within the normal range of 40 to 220 mEq/L/24 hours. The BUN/creatinine ratio is below the 20:1 ratio, which does not support a diagnosis of MODS.

Which characteristics of a second-degree thermal burn would the nurse expect to find during a patient's physical assessment? Select all that apply.

Severe pain Mild edema Fluid-filled vesicles Second-degree burns show epidermal and dermal involvement to varying depths. These burn injuries are characterized by fluid-filled vesicles that are erythematous, glossy, and damp. The patient may complain of severe pain caused by nerve injury. Mild to moderate edema may be present. Waxy, white, hard skin and visible thrombosed vessels are found in third-degree burns.

Which assessment findings would alert the nurse to the presence of an inhalation injury in a burn patient? Select all that apply.

Singed nasal hair Increasing hoarseness Painful swallowing History of being trapped in an enclosed space Reliable clues to the occurrence of inhalation injury include the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being trapped in an enclosed space, altered mental status, and "cherry red" skin color. Burns on the upper extremities do not signify an inhalation injury.

The nurse is assessing a patient admitted after inhalation of toxic chemicals. Which finding by the nurse indicates a lower airway injury?

Singed nasal hairs Singed nasal or facial hair is one of the manifestations of a lower airway injury, involving the trachea, bronchioles, and alveoli. Blisters, total airway obstruction, and substernal retractions can be seen in patients suffering from an upper airway burn injury.

Which drug causes arterial and venous dilation?

Sodium nitroprusside Sodium nitroprusside acts by dilating both the arteries and veins. It is used in the treatment of cardiogenic shock. Dopamine has inotropic activity. It increases the force of the heartbeat and is used in the treatment of cardiogenic shock. Vasopressin is a vasoconstrictor used mainly in the treatment of septic shock. Phenylephrine acts by constricting the peripheral nerves and is used in the treatment of neurogenic shock.

When managing a patient with shock, which actions would the nurse take as part of nutritional therapy? Select all that apply.

Start a slow continuous drip of small amounts of enteral feedings. Start parenteral nutrition if enteral feedings are contraindicated. Start enteral nutrition within the first 24 hours. Enteral nutrition should ideally begin within the first 24 hours. It is important because it enhances the perfusion of the gastrointestinal (GI) tract and helps to maintain the integrity of the gastrointestinal mucosa. Enteral feeding should be started with a slow, continuous drip of small amounts of enteral feedings. If enteral feedings are contraindicated, then parenteral feedings can be started. Nutritional therapy should start as early as possible. The nurse should not wait for the patient to recover before starting nutritional therapy. Enteral feeding should be planned to meet at least 80% of the total calorie requirements, but if it is not feasible, parenteral feeding should be started.

The nurse anticipates which clinical findings in a patient who presents with anaphylactic shock? Select all that apply.

Stridor Pruritus Anxiety Chest pain Clinical findings associated with anaphylactic shock include stridor, pruritus, anxiety, and chest pain. The patient will experience skin flushing, not pallor.

Which prescriptions would the nurse anticipate incorporating into the plan of care for a patient with multiple organ dysfunction syndrome (MODS) who is exhibiting gastrointestinal symptoms including bleeding? Select all that apply.

Sucralfate Omeprazole Maalox Antacids like Maalox, proton pump inhibitors like omeprazole, and sucralfate are all indicated to treat issues related to injury to the gastric mucosa in MODS. Atorvastatin is a cholesterol-lowering agent and thus not indicated in this situation. Loperamide is an antidiarrheal and not appropriate based on the information provided.

A nurse is assessing a patient who was burned after contact with gasoline. Which complication would the nurse monitor?

Systemic toxicity Gasoline is an organic compound that causes chemical burns. This compound produces systemic toxicity in patients. Liquefaction and protein hydrolysis occur due to chemical burns resulting from alkalis. Electrical injury results in severe metabolic acidosis.

Which side effect will the nurse monitor for when administering a β-adrenergic agonist drug to a patient with respiratory failure?

Tachycardia β-adrenergic bronchodilators, such as albuterol, are sympathetic nervous system stimulants and cause tachycardia and hypertension. Lethargy is not an expected side effect of β-adrenergic medications, which are central nervous system stimulants. Hypokalemia may occur with β-adrenergic medications, but hyperkalemia is not an expected side effect. Adrenal insufficiency is not an expected side effect of β-adrenergic medications.

Which manifestations are initial compensatory mechanisms of the respiratory system in patients with shock? Select all that apply.

Tachypnea Hyperventilation

Which life-threatening condition would the nurse monitor for potential development when providing care for a patient receiving positive pressure ventilation (PPV) after sustaining a gunshot wound (GSW) to the chest?

Tension pneumothorax While on positive pressure ventilation, air can escape into the pleural space from the alveoli and become trapped, increasing pleural pressures, collapsing a lung, and causing a tension pneumothorax, which is a life-threatening condition. Detection of emphysema usually does not occur until after the development of a pneumothorax. Pneumonia can occur with PPV, but the pneumothorax is more acutely life-threatening. PPV does not cause COPD.

For the patient receiving mechanical ventilation, which rationale best explains why the nurse would input assessment findings into the electronic health record (EHR)?

The connectivity of monitoring devices and ventilators help to drive evidence-based practice. The connectivity of monitoring devices and ventilators can help to drive evidence-based practice by readily noting trends and linking users to protocols. The ICU or emergency department should have all ventilator information imported to be of use. The skilled teams of specialists do require and need correct information, but the data has to be imported correctly. Accurate information is important, but it must be verified before submitted.

Which patient with respiratory failure is a good candidate for noninvasive positive pressure ventilation (NIPPV)?

The patient who has decreased ventilation because of myasthenia gravis crisis NIPPV is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. Patients who have unstable heart rate and BP and need positive pressure ventilation are intubated since it is more difficult to maintain hemodynamic stability with NIPPV. Since NIPPV requires that the patient be able to breathe spontaneously, a patient with decreased level of consciousness will not be a good candidate. NIPPV requires use of a tight-fitting mask and is not a good positive pressure ventilation method for patients with copious respiratory secretions who will need frequent suctioning.

Which patient who has just arrived in the emergency department will the nurse assess first?

The patient who is sitting in tripod position and not speaking Use of the tripod position, especially in a patient who is unable to speak because of dyspnea, indicates severe respiratory distress; this patient needs rapid assessment and intervention. A patient who can say five words before needing to take a breath may be experiencing mild to moderate respiratory distress and needs assessment, but the patient who is in the tripod position should be assessed first. Nighttime dyspnea needs further assessment for problems such as asthma or obstructive sleep apnea, but this patient is not in any current respiratory distress and can wait to be assessed by the nurse. A patient who experiences labored breathing with ambulation needs assessment but can be asked to rest quietly to decrease work of breathing and does not need immediate assessment or intervention.

When four patients arrive in the emergency department reporting respiratory distress, which patient will the nurse assess first?

The patient whose chest and abdomen are moving inward during inspiration Movement of the chest and abdomen inward during inspiration is paradoxical breathing and indicates severe respiratory distress; the nurse will assess this patient initially since rapid interventions are needed. Pursed-lip breathing is used by many patients with asthma and chronic obstructive pulmonary disease to help improve expiration but does not necessarily indicate severe respiratory distress. A patient who can tolerate the head elevated at about 45 degrees is likely in mild-to-moderate respiratory distress. A patient who needs to breath after saying three words is certainly in respiratory distress but not as severe as a patient with paradoxical breathing.

The nurse reviews the plan of care for a patient with multiple organ dysfunction syndrome (MODS). Which outcome would be desirable for this patient?

The patient will demonstrate improved perfusion and oxygenation of organs. The underlying pathophysiology of MODS is a lack of perfusion to organs, resulting in tissue and/or organ hypoxia. Interventions to improve perfusion with fluids or medications improve patient outcomes. The outcomes listed in the other answer options are appropriate and desirable for the patient with MODS, but they are secondary to improved perfusion and oxygenation.

Which structure of the skin would the nurse identify as affected in a deep partial-thickness burn?

The structure A in the image indicates the dermis. In a deep partial-thickness burn, the structures involved are the epidermis and dermis to varying depths. It is known as a second-degree burn. The structure B is fat, and structures C and D are muscle and bone, respectively. These three structures are involved in full-thickness burns, which are third- and fourth-degree burns.

In which order would the nurse complete the steps for a passive leg raise challenge?

When performing a passive leg raise, the patient is placed supine, and the nurse then raises the patient's legs to 45 degrees. The nurse measures responsiveness in one to two minutes by measuring cardiac output. The nurse then evaluates the patient for hemodynamic improvement.

When providing care for a patient receiving mechanical ventilation after sustaining a motor vehicle accident two weeks ago, which assumption would the intensive care nurse make about with this situation?

The ventilator will support the patient until he or she can breathe on his or her own. Mechanical ventilation is not curative. It is a means of supporting patients until they recover the ability to breathe independently. Decisions to use, withhold, or withdraw mechanical ventilation require careful consideration, involving the agency's ethics committee for assistance. The patient's medical history or diagnosis is not known; the nurse does not know whether the patient suffered from chronic pulmonary disease or whether the patient has severe hypoxia.

The nurse suspects a burn injury patient has superficial partial-thickness burns. Which findings would the nurse expect to find? Select all that apply.

There is blanching with pressure. The burned area has minimal edema. Wounds are red and painful. In cases of superficial partial-thickness burns, wounds appear red and painful. This is due to the superficial epidermal damage causing hyperemia. The tactile and pain sensation remains unaffected. There is blanching with pressure due to superficial epidermal damage. The burned area has minimal edema because only the superficial layers are involved. In cases of full-thickness burns, the wounds become dry and leathery, and all the skin elements are destroyed. Wounds are moist and blistered in deep partial-thickness burns. This is because varying depths of epidermis and dermis are involved, and it causes formation of fluid-filled vesicles. These have a wet appearance if the vesicles rupture.

Upon review of a patient's ventilator settings, which setting parameters would the nurse identify as abnormal?

Tidal volume of 12 mL/kg Usual tidal volume is 6 to 10 mL/kg; a tidal volume of 12 mL/kg is abnormally high. A respiratory rate of 20 breaths/minute is within normal; usual settings are 6 to 20 breaths/minute. A PaO2 level of 66 mm Hg is normal; the usual level is greater than 60 mm Hg. PEEP of 5 cm H2O is the usual setting.

Place the activities of the nurse preparing to suction a patient receiving mechanical ventilation in progressive order.

To begin suctioning procedures for a patient on mechanical ventilation, the nurse first gathers all equipment and then washes his or her hands and puts on PPE. Next, the nurse explains the procedure to the patient and the patient's role in secretion removal by coughing. The nurse then monitors the patient's cardiopulmonary status before, during, and after the procedure and then turns on suctioning and sets the vacuum to 100 to 120 mm Hg. Finally, the nurse can pause the ventilator alarms.

While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. Which are the reasons behind this action? Select all that apply.

To decrease pain To prevent blistering To decrease itchiness The interim pressure from tubular elastic gauze decreases pain and itchiness and prevents blistering. It promotes venous return rather than reducing it. It does not enhance local immunity.

Which factor would the nurse identify as the cause of pulmonary edema in a patient with multiple organ dysfunction syndrome (MODS)?

Uncontrolled systemic inflammation During sepsis, early activation of immune cells is followed by down-regulation of their activity, which leads to a state of immune deficiency and increased risk of superinfection. Proinflammatory mediators increase capillary permeability, resulting in edema in organs such as the lungs. This is why the patient is developing pulmonary edema. Evidence of tissue hypoxia will occur in the gastrointestinal tract and the brain first. Unregulated apoptosis is uncontrollable cellular death. Pulmonary edema is not a symptom of unregulated apoptosis. Microvascular coagulopathy will manifest as abnormal clotting factors and microembolism production.

Which finding in a patient with multiple organ dysfunction syndrome (MODS) suggests that the patient has acute tubular necrosis?

Urine Na+ is 22 mEq/L. A urine Na+ greater than 20 mEq/L is suggestive of acute tubular necrosis. A bilirubin level higher than 2 mEq/L suggests hepatic dysfunction rather than renal dysfunction. Urine-specific gravity above 1.020 and a BUN/creatinine ratio higher than 20:1 indicate renal hypoperfusion rather than acute tubular necrosis.

Which areas would the nurse assess to evaluate end-organ perfusion when caring for a patient who received fluid volume resuscitation for septic shock? Select all that apply.

Urine output Peripheral pulses Neurologic function The goal for fluid resuscitation is restoration of tissue and end-organ perfusion. An assessment of end-organ perfusion includes urine output, peripheral pulses, and neurologic function. Visual acuity, oral mucosa, and bowel sounds do not provide relevant data for the nurse to evaluate end-organ function.

Which laboratory finding in a patient with multiple organ dysfunction syndrome (MODS) suggests prerenal manifestations of renal dysfunction?

Urine specific gravity is increased. An increase in urine specific gravity suggests prerenal manifestations in patients with MODS. This occurs due to renal hypoperfusion. A urine Na+ level above 20 mEq/L is a sign of intrarenal manifestations in MODS. It occurs due to acute tubular necrosis. Other intrarenal manifestations of MODS are urine specific gravity of around 1.010 and a decrease of the urine osmolality.

In patients with systemic inflammatory response syndrome (SIRS), which manifestations of acute tubular necrosis differ from those of renal hypoperfusion?

Urine-specific gravity is around 1.010 in acute tubular necrosis and greater than 1.020 in renal hypoperfusion. In patients with acute tubular necrosis, the urine-specific gravity is around 1.010, whereas it is greater than 1.020 in patients with renal hypoperfusion. Urine Na + is greater than 20 mEq/L in patients with acute tubular necrosis and greater than 20 mEq/L in patients with renal hypoperfusion. Urine osmolality is decreased in cases of acute tubular necrosis, whereas it is increased in cases of renal hypoperfusion. Blood urea nitrogen/creatinine ratio is less than 10:1 to 15:1 in cases of acute tubular necrosis and greater than 20:1 in cases of renal hypoperfusion.

Which complications would the nurse monitor for in a patient receiving 5% human serum albumin? Select all that apply.

Urticaria Fluid overload Colloidal solutions such as 5% human serum albumin may cause fluid and sodium retention, resulting in fluid overload. Therefore to prevent the risk of fluid overload in the patient, the nurse should check for signs of fluid overload, or hypervolemia. Colloidal solutions can cause chills, fever, and urticaria. Therefore the nurse should assess the patient for symptoms of urticaria in order to provide appropriate treatment. Unlike dextrose, human serum albumin does not increase the risk of bleeding in the patient. Human serum albumin causes sodium retention, so the nurse should check for the symptom of hypernatremia, not hyponatremia. Human serum albumin does not cause a decrease in plasma bicarbonate concentration and does not result in hyperchloremic acidosis.

Which prescribed intervention will the nurse implement first for an unresponsive patient admitted with a barbiturate overdose who has BP 90/60 mm Hg, apical pulse 110, and respiratory rate 8?

Use a bag-valve-mask system to ventilate the patient. Because a patient with a respiratory rate of 8 is likely to have both hypoxemic and hypercapnic respiratory failure, the nurse's initial action will be to assist the patient with ventilation using a bag-valve-mask system and anticipate the need for endotracheal intubation to support respirations. The BP and heart rate indicate possible sepsis or hypovolemia, and IV fluid is needed, but improving oxygenation and ventilation has a higher priority. ABGs are likely to be needed, but the nurse will not wait for ABGs before assisting the patient's ventilation. Past medical history will be needed to help to guide care, but this will be obtained after the respiratory status has been stabilized.

Which action will the nurse take when caring for a patient with acute respiratory failure due to left-sided pneumonia?

Use huff coughing to help to clear secretions. Huff coughing helps to clear respiratory secretions from the central airways. Suctioning is indicated only when the patient's condition warrants it (for example, an ineffective cough) and is not scheduled. Hyperventilation may be used before treatments, repositioning, interventions, and so forth to allow the patient to have a reserve of oxygen prior to stressful activities. Positioning for optimal oxygenation and ventilation is good lung down, not up.

Which action will the nurse take when the arterial blood gas results for a 76-year-old patient indicate a PaO2 of 76 mm Hg?

Use pulse oximetry to monitor the patient's oxygen saturation. While the normal PaO2 is 80 to 100 mm Hg, aging affects normal arterial blood gas (ABG) values, and there is no indication that this patient needs anything more at this time than monitoring. Oxygen therapy at 2L/min is not indicated for a PaO2 level that is within the normal limits for the patient's age. The health care provider does not need to be notified immediately about a normal finding. There is no indication that intubation is needed for the patient.

Which manifestations are pathophysiologic effects of septic shock? Select all that apply.

Vasodilation Myocardial depression Maldistribution of blood flow Septic shock has three major pathophysiologic effects: vasodilation, myocardial depression, and maldistribution of blood flow. The release of platelet-activating factors increases coagulation rather than decreasing it, resulting in the formation of microthrombi and decreased blood flow in the microcirculation. Because coagulation is increased, blood flow in the microcirculation is decreased, not increased. Sepsis-induced myocardial dysfunction results in a decreased, not increased, ejection fraction.

Which information will the nurse educator include when teaching staff nurses about hypercapnic respiratory failure? Select all that apply.

Ventilatory failure leads to carbon dioxide (CO2) retention in arterial blood. Arterial carbon dioxide (PaCO2) is greater than 50 mm Hg, and arterial pH is less than 7.35. With hypercapnic respiratory failure, ventilatory failure leads to carbon dioxide retention, resulting in PaCO2 levels higher than 50 mm Hg. In addition, the normal kidney compensatory mechanisms fail, leading to a pH less than 7.35. While arterial oxygen level is sometimes also low, patients can have normal or high oxygen levels with hypercapnia, and the major abnormality in hypercapnic respiratory failure is an elevation in PaCO2. The arterial blood pH decreases as the high PaCO2 leads to increased blood carbonic acid levels. Inadequate transfer of oxygen from the alveoli to pulmonary capillaries leads to hypoxemic respiratory failure; in hypercapnic respiratory failure, oxygenation may be normal or abnormal.

Which condition does a patient with cardiogenic shock typically experience?

Volume excess In cardiogenic shock, the heart fails as a pump. This usually results in fluid retention and poor perfusion of organs, including the kidneys, which adds to the fluid volume excess. As cardiogenic shock progresses, hypotension will develop, but it is not the cause of cardiogenic shock. Dysrhythmias may or may not be present with cardiogenic shock. Volume depletion is not generally seen with cardiogenic shock. It is, however, seen more with hypovolemic or distributive forms of shock.

Which characteristics would the nurse likely find when performing an examination of a patient's deep partial-thickness burn? Select all that apply.

Wounds are wet and shiny. Wounds appear pink to cherry-red. Wounds are painful to touch. Partial-thickness wounds are wet and shiny due to serous exudates. These wounds are painful to touch due to nerve injury. Wounds appear pink to cherry-red. Wounds are painless in full-thickness burns due to nerve destruction. Wounds appear black and leathery in full-thickness burns because all skin elements and local nerve endings are destroyed, and coagulation necrosis is present.

When instructing a community group about caring for a person with burns of more than 10% of total body surface area, which would the nurse advise? Select all that apply.

Wrap the patient in a blanket. Gently remove burned clothing. Leave adherent clothing in place. In the case of severe burns, the patient should be wrapped in a blanket to avoid further contamination and to provide warmth. Burned clothing should be gently removed to prevent further tissue damage. Adherent clothing should be left in place until the patient is transferred to the hospital to avoid tissue damage. Leaving the affected area open to air can cause more contamination and is not advisable. Applying ice all over the burned area can cause hypothermia and is not advisable.

The nurse and health care provider plan to provide an antioxidant regimen for a patient with partial-thickness burns in the acute phase. Which antioxidants would the nurse identify as being included in the protocol? Select all that apply.

Zinc Selenium Multivitamins Zinc is an antioxidant and also a part of the antioxidant protocol because it supports cell growth and development. Selenium is used in the antioxidant protocol, because it helps to prevent cell damage. Multivitamins are a part of the antioxidant protocol because they help to compensate for the nutritional deficiencies of essential vitamins and minerals. Water is useful for the patient but does not form a part of the antioxidant protocol. Calcium is important to maintain strong bones and teeth, but it is not included in the antioxidant protocol.