NUR final
An adult patient who was in an apartmennt building fire is brought into the ED . The patient weighs 154lbs and has burns over 60% of their TBSA. Calculate the total amount of fluid the patient should receive in 24 hours according to the Parkland formula 1._________. How much of that fluid should be given in the first 8 hours? 2.______
1. 16,800 2. 8,400 Parkland formula - 4ml x %burn x kg = total fluid in 24 hours. Give half of total within 8 hrs
The nurse has an order to apply 2 inches of 2% nitroglycerine paste to a patient for autonomic dysreflexia. The nurse assessed the patient to be developing an episode of autonomic dysreflexia. Where on the patient's body should the nurse apply the nitro paste? 1.______________. Once the patient's blood pressure stabilizes, should the nurse: apply a 2nd dose of nitroglycerine, wipe off the nitroglycerine, or start an infusion of IV nitroglycerine? 2. ________________________
1. 2 inches above 2. wipe off.
A patient is in ventricular bigeminy. The provider orders a lidocaine drip at 3mg/min. the lidocaine comes prepackaged with 2 grams of lidocaine in 500ml of D5W. At what rate will the nurse set the infusion pump?
45ml/hr
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which client is most likely to have life threatening complications? A. A 4 year-old scald victim burned over 24% of the body B. A 27 year-old male burned over 36% of his body in a car accident C. A 39 year-old female client burned over 18% of her body D. A 60 year-old male burned over 16% of his body in a brush fire.
A. A 4 year-old scald victim burned over 24% of the body
A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patient's needs? A. A patient-controlled analgesia (PCA) system B. Oral opioids supplemented by NSAIDs C. Distraction and relaxation techniques supplemented by NSAIDs D. A combination of benzodiazepines and topical anesthetics
A. A patient-controlled analgesia (PCA) system
The client is found to have Vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. A. avoid rectal temperatures B. Use only a soft toothbrush C. Monitor the platelet count D. Use the smallest gauge needles possible for any injections E. Assess for asterixis F. Prepare for an immediate liver biopsy
A. Avoid rectal temp B. Use only a soft toothbrush C. Monitor the platelet count D. Use the smallest gauge needles possible for any injections
The nurse is caring for a client recently diagnosed with acute kidney disease. which of the following lab values would be most important for the nurse to monitor to determine if the client's condition is resolving? A. BUN and Creatinine B. WBC and hemoglobin C. Potassium and sodium D. bilirubin and ammonia levels.
A. BUN and Creatinine
An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 44% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A. Begin administering isotonic IV fluids B. Start broad spectrum antibiotics until cultures are obtained C. Prepare to administer IV potassium chloride D. Administer packed red blood cells.
A. Begin administering isotonic IV fluids
A patient who develops neurogenic pain following a spinal cord injury will often describe it in which of the following ways. A. Burning and stinging. b. Dull and throbbing C. Sharp and intermittent D. Cramping that comes and goes.
A. Burning and stinging.
The nurse is assessing a patient who has a positive spinal cord injury. When determining if the patient may have respiratory distress related to paralysis of the diaphragm the nurse would be most concerned about an injury to which of the following spinal nerves? A. Cervical B. Lumbar C. Sacral D Thoracic
A. Cervical
A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, What would be the nurses immediate, priority concern when planning this clients care? A. Fluid status. B. Risk of infection C. Nutritional Status D. Psychosocial coping
A. Fluid status.
A client is brought to the ED with a sever burn injury. The nurse knows that the first systemic event after a major burn injury is what event? A. Hemodynamic instability B. Gastrointestinal hypermotility C. Hypokalemia D. Respiratory arrest
A. Hemodynamic instability
A nurse is caring for a patient admitted for heat stroke. The nurse monitors for which common electrolyte abnormality? A. Hyperkalemia B. Hypernatremia C. Hypokalemia D. Hyponatremia
A. Hyperkalemia
A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B. Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C. Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D. Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
A patient with end stage kidney disease receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action? A. Inform the physician and assess the patient for signs of infection B. Flush the peritoneal catheter with normal saline C. Remove the catheter promptly and have the catheter tip cultured D. Administer a bolus of IV normal saline as ordered.
A. Inform the physician and assess the patient for signs of infection
A patient is admitted to the burn unit after being transported from a facility 400 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs which happened 6 hours ago. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A. Ischemia B. Referred pain C. Cellulitis D. Venous thromboembolism.
A. Ischemia
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patient's care? A. Monitoring the patient's fluid status B. Determining the patient's risk of infection C. Assessing the patient's nutritional needs D. Providing support for psychosocial coping
A. Monitoring the patient's fluid status
Following a spinal cord injury, the patient exhibits a decrease in blood pressure, heart rate, and cardiac output, the ER nurse knows these to be signs of: A. Neurogenic shock B. Spinal shock C. paralysis D. Muscular flaccidity
A. Neurogenic shock
Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complications? A. Peritonitis B. Gastritis C. Gastroesophageal reflux D. Acute pancreatitis.
A. Peritonitis
The client receiving hemodialysis is complaining of starting to feel dizzy and lightheaded. Which action should the nurse implement first? A. Place the client in the Trendelenburg position B. Turn off the dialysis machine immediately C. Blus the client with 1000mL of normal saline D. notify the healthcare provider immediately
A. Place the client in the Trendelenburg position
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A. Sodium deficit B. Decreased prothrombin time (PT) C. Potassium deficit D. Decreased hematocrit
A. Sodium deficit
A pt is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which of the following interventions should the nurse implement first? A. Start an IV with a 16-18 G catheter B. Initiate a norepinephrine infusion C. Obtain ABG's D. Insert an indwelling foley catheter.
A. Start an IV with a 16-18 G catheter
Which of the following actions by the UAP would warrant intervention by the nurse? A. The UAP is assisting the client to take a hot, soapy shower B. The UAP applies an emollient to the clients legs and back C. The UAP pats the clients skin dry with a clean towel D. The UAP assists the clint to file their fingerprints
A. The UAP is assisting the client to take a hot, soapy shower
A nurse is preparing to provide care for a patient with exacerbation of ulcerative colitis and required hospital admission. During the exacerbation of this health problem, the nurse would anticipate that the patient's stool will have which characteristics? A. Watery with blood and mucus B. Heard an black or tarry C. Dry and streaky with blood D. Loose with visible fatty streaks.
A. Watery with blood and mucus
The leading case of spinal cord injuries in the United States: A. motor vehicle accidents B. Falls C. Violence like gunshots and other weapons D. Sports
A. motor vehicle accidents
An 18 year old student is admitted with dark urine, fever and flank pain. The student is diagnosed with glomerulonephritis. Which of the following would most likely be in the students history? A. sore throat B. Renal trauma C. Renal calculi D. Family history of glomerulonephritis
A. sore throat
BOWTIE: A patient who has severe burns to 75% of her body after being pulled from a burning car is admitted to the emergency department. The nurse is developing a plan of care. Determine which complication is indicated by choosing the correct condition with 2 parameters to monitor and 2 actions to take. Actions to take: A. Initiate a large bore peripheral IV ; B. Administer antibiotics as ordered ; C. Prepare for an escharotomy ; D. Start Lactated Ringers IV solution ; E. Administer morphine sulfate IVP as ordered. Potential Conditions: A. Infection ; B. Compartment Syndrome ; C. Dehydration ; D. Pain Parameters to monitor: A. Temperature ; B. Blood pressure ; C. Weight ; D. Urine output ; E. Pedal pulses
Acitons to Take: Start IV, Administer LR Condition: Dehydration Monitor: U/O, Pedal pulse ????????
Which of the following go with Chron's Disease or Ulcerative Colitis: Autoimmune disease Affects the large intestine Affects only the mucosal and submucosal layers of the intestine Patients have persistent diarrhea Damaged areas of the intestine are in patches in between healthy tissues Treatment is with corticosteroids
Autoimmune disease: BOTH Affects the large intestine: Ulcerative Colitis Affects only the mucosal and submucosal layers of the intestine: Ulcerative Colitis Patients have persistent diarrhea: Ulcerative colitis Damaged areas of the intestine are in patches in between healthy tissues: Chron's Disease Treatment is with corticosteroids: BOTH?
A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member? A. " The client is on a calorie-restricted diet in order to divert energy to wound healing" B. " The client's body is consuming fat for fuel because calorie need is higher than normal for healing" C. "The client actually hasn't lost weight. Instead, there's been a change in the distribution of body fate." D. " The client lost many fluids while being treated in the emergency phase of burn care."
B. " The client's body is consuming fat for fuel because calorie need is higher than normal for healing"
The current phase of a clients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? A. Emergent or resuscitative B. Acute or Intermediate C. Rehabilitative or restorative D. Recovery or final phase
B. Acute or Intermediate
A patient with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). What intervention by the nurse will determine the effectiveness of treatment? A. Carrying out a hemocult test on gastric fluids after the infusion is completed B. Checking the frequency and consistency of bowel movements C. Monitoring the leukocyte count for 3 days after infusion D. Checking liver enzyme levels before and after infusion.
B. Checking the frequency and consistency of bowel movements
The nurse is caring for a client who may have developed acute renal failure. Which condition predisposed the client to developing prerenal failure? A. Diabetes mellitus B. Hypotension C. Aminoglycosides D. Benign prostatic hypertrophy
B. Hypotension
The nurse is preparing a presentation for the community on prevention of carbon monoxide poisoning. Which of the following would the nurse include? Select all that apply. A. Carbon monoxide smells like rotten eggs B. Oil and gas furnaces should be inspected yearly to be sure they are functioning well. C. When using a generator inside the house, be sure the window is cracked. D. Carbon monoxide detectors should be installed near all sleeping areas. E. Carbon monoxide binds to hemoglobin to form carboxyhemoglobin F. Administer oxygen to a patient with CO poisoning only if their pulse oximetry is <95% G. Skin color is not a reliable assessment in CO poisoning
B. Oil and gas furnaces should be inspected yearly to be sure they are functioning well. D. Carbon monoxide detectors should be installed near all sleeping areas. E. Carbon monoxide binds to hemoglobin to form carboxyhemoglobin G. Skin color is not a reliable assessment in CO poisoning
What is the best way to warm a patient's feet that are showing signs of frostbite? A. Wrap the feet in a warm blanket B. Place feet in warm water C. Place their feet in cool water to allow them to thaw gradually D. Rub the feet to improve circulation
B. Place feet in warm water
A patient who was burned in a workplace accident has competed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A. Monitoring fluid and electrolyte imbalances B. Providing education to the patient and family C. Treating infection D. Promoting thermoregulation
B. Providing education to the patient and family
The nurse is providing education to a client that is scheduled for mechanical debridement of a wound. the nurse knows that mechanical debridement involves which element? A. A spontaneous separation of dead tissue from the viable tissue B. Removal of eschar until the point of pain and bleeding occurs C. Shaving of burned skin layers until bleeding, viable tissue is revealed. D. Early closure of the wound.
B. Removal of eschar until the point of pain and bleeding occurs
Which of the following are possible causes of autonomic dysreflexia? select all that apply. A. Depression B. Skin damage C. Constipation D. Real Calculi E. Hemorrhoids F. Fractured arm G. Sexual intercourse H. Urinary Tract infection
B. Skin damage C. Constipation D. Real Calculi E. Hemorrhoids F. Fractured arm G. Sexual intercourse H. Urinary Tract infection
Which of the following best describes why spinal shock occurs in patients with a spinal cord injury? A. Constriction of blood flow in the area results in tissue ischemia and damage to the spinal nerves. B. Swelling and disrupted blood flow to the area alters the body's ability to self-regulate C. The injury results in the activation of the body's immune response and capillary clotting. D. Hemorrhage into the injured spinal cord causes loss of blood.
B. Swelling and disrupted blood flow to the area alters the body's ability to self-regulate
The nurse in the dialysis center is initiation the morning dialysis run. Which client should the nurse asses first? A. the client who has a hemoglobin of 9.8 and hematocrit of 30% B. The client who does not have a palpable thrill or auscultated bruit C. The client who is complaining of being tired and is sleeping D. The client who did not take his antihypertensive medication this morning.
B. The client who does not have a palpable thrill or auscultated bruit
The nurse is developing a plan of care for the client's problem of "excess fluid volume". Which short term goal would be most appropriate for this client? A. The client will not gain more than 3kg a day. B. The client will have no increase in abdominal girth when measured daily C. The client's vital signs will be normal D. the client will be given low sodium diet.
B. The client will have no increase in abdominal girth when measured daily
the nurse in a disaster is triaging the following clients. Which client should be triages as a LAST priority? A. The client with a sucking chest wound who is alert B. The client with a severe head injury who is unresponsive C. The patient with an abdominal wound who has stable vital signs D. The patient with a sprained ankle that may be fractured and is cool to the touch.
B. The client with a severe head injury who is unresponsive This patient has the least likelihood of making it since this is a disaster triage.
A patient with peptic ulcer disease has presented to the emergency department in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? A. The patient has abdominal bloating that developed rapidly B. The patient has a rigid. "boardlike" Abdomen that is tender. C. The patient has anorexia and vomiting. D. The patient is diaphoretic and complaining of right lower quadrant abdominal pain.
B. The patient has a rigid. "boardlike" Abdomen that is tender.
A nurse is caring for a client with acute kidney failure. The nurse understands that the most accurate indicator of fluid loss or gain in an acutely ill client is which of the following? A. Blood pressure B. Weight C. Heart rate D. Edema
B. Weight
Which assessment question is a priority for a patient with hepatic encephalopathy who has admitted to continue to drink alcohol" A. "How many years have you been drinking alcohol" B. " Have you completed an advanced directive?" C. " When did you have your last drink" D. "When did you last have something to eat?"
C. " When did you have your last drink"
A patient is brought into the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temp of 104.2F. What would be the priority nursing action for this patient? A. Monitor cardiovascular effects B. Administer antipyretics C. Ensure airway and ventilation D. Prevent seizure activity.
C. Ensure airway and ventilation
A client is brought to the emergency department from the site of a chemical fire, where the client suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the clients arm? A. Partial thickness B. Superficial C. Full thickness D. Unable to determine from the description
C. Full thickness
A client with a cervical fracture is being discharged in with a halo device, Which teaching instructions should the nurse discuss with the client? A. Discuss how to correctly remove the pins to take the Halo device off at night B. Encourage the client to spend as much time as possible resting in a recliner C. Have a friend or family member drive them where they need to go D. Inform the client that the vest liner cannot be changed and they cannot wash under the liner
C. Have a friend or family member drive them where they need to go
a 3 year-old child has sustained significant severe burns and is ordered to receive 100% oxygen. Which of the following would the nurse use to administer the oxygen? A. Nasal Canula B. Venturi mask C. Nonrebreather mask D. Oxygen hood.
C. Nonrebreather mask
A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A. Obtain an order to reduce the rate of the patient's IV fluid infusion B. Report the patient's early signs of acute kidney injury C. Recognize that the patient is experiencing an expected onset of diuresis D. Administer sodium chloride as ordered to compensate for the fluid loss.
C. Recognize that the patient is experiencing an expected onset of diuresis
The nurse is assessing a patient with a spinal cord injury at the level of C5. The nurse suspects the patient may be experiencing autonomic dysreflexia. Which of the following are signs or symptoms of this. Select all that apply. A. Hypotension B. Flushing of skin below the level of the spinal cord injury C. Severe pounding headache D. Blurred Vision E. Nasal congestion. F. Feelings of anxiety G. Profuse diaphoresis.
C. Severe pounding headache D. Blurred Vision E. Nasal congestion. F. Feelings of anxiety G. Profuse diaphoresis You would see hypERtention and flushing ABOVE the injury
The nurse is caring for a client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? A. There is an increased excretion of phosphates which leads to an increase in arterial blood pH B. A shortened life span of red blood cells because of damage secondary to dialysis treatments leads to metabolic acidosis C. The kidney cannot reabsorb sodium bicarbonate D. An increase in nausea and vomiting causes a loss of hydrochloric acid.
C. The kidney cannot reabsorb sodium bicarbonate
A nurse is developing a plan of care for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment . What is the best rationale for this interventions? A. To prevent neuropathies B. To prevent wound breakdown C. To prevent contractures D. To prevent heterotopic ossification.
C. To prevent contractures
The parents of a toddler come into the ED stating the child drank an unknown amount of a cleaning solution. What is the first thing the nurse should do?
Contact the Poison Control Center
The client asks the nurse. "Why is my doctor decreasing the dose on some of my medications?" Which statement is the nurses best response? A. "You are worried because your doctor has decreased the dosage. Your doctor knows best" B. "You really should ask your doctor. I'm sure there is a good reason or they would not have changed it" C. "The half-life of the medication is altered because of the alcohol you drank damaged your liver" D. " the level of some medications may get to high because your liver is damaged and cannot process the medications as well as it could before."
D. " the level of some medications may get to high because your liver is damaged and cannot process the medications as well as it could before."
The nurse is developing a plan of care for a client diagnosed with acute kidney disease. Which statement is an appropriate outcome for the client? A. Delegate monitoring intake and output every shift to the UAP B. Administer enema's as ordered to decrease hyperkalemia C. Decrease level of pain by three levels on a 1-10 scale D. Client's electrolytes will be within normal limits by 8am tomorrow.
D. Client's electrolytes will be within normal limits by 8am tomorrow.
A nurse is caring for a 14-year old girl who received an electrical burn. Based on this type of burn, the nurse would anticipate preparing the child for which diagnostic tests as ordered? A. pulse oximetry B. Fiberoptic bronchoscopy C. Ventilation-perfusion scanning D. Electrocardiogram (EKG)
D. Electrocardiogram (EKG)
a 6 year-old boy has been admitted to the hospital with burns. The nurse notes carbonaceous sputum. Which of the following would be the priority? A. Determining the burn depth B. Eliciting a description of the burn C. Estimating burn extent D. Ensuring a patent airway
D. Ensuring a patent airway
A patiet's burns are estimated at 36% TBSA; fluid resuscitation ahs been ordered in teh emergency department. After establishing IV access, the nurse should anticipate the administration of what fluid? A. 0.45% NaCl with 20 mEq/L KCl B. 0.45% NaCl with 40 mEq/L KCl C. D5W D. Lactated Ringers.
D. Lactated Ringers.
A patient has 20% TBSA deep partial thickness and full thickness burn to the right anterior chest and entire right arm. Which of the following is the most important that the nurse assess the patient for? A. Presence of pain B. Swelling of the arm C. Formation of eschar. D. Presence of pulses in the arm
D. Presence of pulses in the arm
What is the initial intervention in the emergency management of a burn of any type? A. Establish and maintain an airway B. Assess for other associated injuries C. Establish an IV line with a large bore needle D. Remove the patient from the burn source to protect the patient and others.
D. Remove the patient from the burn source to protect the patient and others.
As part of a clinical conference with a group of nursing students, the instructor is describing the burn classification. The instructor determines that the teaching has been successful when the group identifies which of the following as characteristics of full thickness burns? A. Skin that is reddened, dry, and slightly swollen B. Skin appearing wet with significant pain C. Skin with blistering and swelling D. Skin that is leathery and dry with some numbness
D. Skin that is leathery and dry with some numbness
The client is scheduled for a paracentesis. Which client teaching should the nurse complete with the client? A. Explain the procedure will be performed in the OR and the client will receive general anesthesia so they will not remember it B. Instruct the client that a foley will be inserted for the procedure C. Provide the client with instructions to hold their breath while the provider inserts the catheter so their lungs are not injured D. Tell the client the nurse will be taking vital signs frequently both during and after the procedure and this is normal
D. Tell the client the nurse will be taking vital signs frequently both during and after the procedure and this is normal
An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to the injury? A. The length of time since the burn. B. The location of the burn C. The source of the burn. D. The TBSA affected by the burn.
D. The TBSA affected by the burn
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. the next step is to "cool the burn". How should the nurse cool the burn? A. Apply ice to the site of the burn for 5 - 10 mins B. Wrap the client's affected extremity in ice until help arrives. C. Apply an oil-based substance to the burn area until help arrives. D. Wrap cool, wet towels around the affected extremity.
D. Wrap cool, wet towels around the affected extremity.
A nurse is caring for a patient with an epidural who has numbness to the level of T12 and L1. Mark on the figure below where the patient is starting to feel numbness.
O->--*-< hehe
A nurse is caring for a patient who has just been diagnosed with a peptic ulcer. When teaching the patient about this new diagnosis, how should the nurse best describe a peptic ulcer?
Open sores that develop on the inside lining of the stomach and upper portion of the small intestine
Indicate whether each of the below occur during the primary spinal cord phase or during the secondary spinal cord phase. Severed Axons Macrophage infiltration necrotic cell death gray matter hemorrhage and ischemia initiation of scar formation
Primary Phase: Severed axons Grey matter hemorrhage Necrotic cell death Secondary Phase: Macrophage infiltration Ischemia initiation of scar formation
A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock A. Confusion B. High fever C. Decreased blood pressure D. Sudden agitation
decreased BP
Turners sign
grey-blue discoloration on flank (Pancreatitis)
