Study
The nurse is caring for a client who has et hoon admitted from an out patient clinic with Time left 0:46:06 multiple myeloma . The client has the following laboratory values : Na 138 mEq / L K 4.0 mEq / L Glucose 110 mg Ca 15.2 mEq / L Creatine 1.2 mg / dL What is the priority nursing action ?
. Initiate intravenous fluids as prescribed .
An 80 - kg patient with burns over 30 % of total body surface area ( TBSA ) is admitted to the burn unit . Using the Parkland formula of 4 ml / kg / % TBSA , what is the IV pump infusion rate ( mL / hour ) for lactated Ringer's solution that the nurse will give during the first 8 hours ? Submit answer in a whole number without units / label .
600 ML
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula . The initial volume of fluid to be given in the first 24 hours is 30,000 mL . The initial rate of administration 1875 ml / hr . After the first 8 hours , what rate should the nurse infuse the IV fluids ?
938 ml / hr
A client is in septic shock subsequent to a perforation of the bowel . The client is being treated with vasopressin . Which would indicate that the medication is effective ?
A change in the serum potassium levels
Which action will the nurse include in the plan of care for a patient who has thalassemia major ?
Administer chelation therapy as needed .
The RN is preparing a patient who has a thermal burn for transfer to a regional burn center and knows that the following should be done . Select all that apply .
Administer tetanus prophylaxis Administer Lactated Ringer's IV based on ABA or Parkland protocol Administer morphine
The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura ( ITP ) . What is a priority nursing action in the care of this patient
Administration of oral or IV corticosteroids
priority nursing action in the care of this patient ? The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura ( ITP ) . What is a
Administration of oral or IV corticosteroids
A patient arrives to the ED after experiencing burns while in an enclosed warehouse.which assessment findings below demonstrate the patient may have exsperienced an inhalation injury?
Carbonaceous sputum Hoarse voice Bright red lips . Tachycardia
A patient is being treated for hemorrhagic shock secondary to multiple rib fractures and a lacerated liver . Two units of packed red blood cells have been administered . Which assessment is an indicationthat the patient has received adequate volume replacement ?
Decreasing serum lactic acid
An adaptation that normally occurs 2-5 days after a severe burn is:
Diuresis
Twelve hours after the patient was involved in a traumatic accident , bowel sounds are absent in all four abdominal quadrants . Which is the nurse's best action ?
Document the findings
A client has undergone coronary artery bypass graft surgery , which was complicated by prolonged cardiopulmonary bypass and hypotension after 3 hours The clients condition stabilizes to a normal blood pressure however the urine output remains insufficient the nurse suspects the physician to add which drug at which flow rate to the clients regimen
Dopamine 3 mcg / kg / minute
The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse temperature 101.5F (38.6 degrees *C) blood pressure is 92/36 mm Hg, and heart rate is 114 bpm with SPO2 of 88% on oxygen at 2 1pm per nasal cannula (previous Spo2 94/%) A saline lock has been established which prescription should the nurse implement first
Draw blood cultures
As the RN providing care to a patient who experienced a full - thickness electrical burn you know to monitor the patient's urine for :
Hemoglobin and myoglobin
A client in the emergent / resuscitative phase of a burn injury has had their lab work drawn . Upon analysis of the client's laboratory studies , the nurse will expect the results to indicate what ?
Hyperkalemia , hyponatremia , elevated hematocrit , and metabolic acidosis
The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock . In light of this intervention , for what sign or symptom should the nurse monitor ?
Hypothermia
The administration of phenylephrine would be least beneficial in which shock state ?
Hypovolemic
On admission to the burn unit a patient with an approximate 25% total body surface area (TBSA) burn has the following intial laboratory results:Hct 58% Hahn 18.2 mg/dl K+ 4.9 Meq/L and Nat 135 mEq/L which of the following prescribe actions should be the nurse priority.
Increasing the rate of the ordered IV solution
A patient with shock of unknown etiology has a BP 92/54 , pulse 64 bpm , and an elevated central venous pressure ( CVP ) reading . Which intervention will the nurse question
Infuse normal saline at 150 ml / hr . ?
A patient has just been admitted with a 40 % total body surface area ( TBSA ) burn injury . To maintain adequate nutrition , the nurse should plan to take which action ?
Insert a feeding tube and initiate enteral nutrition .
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance the nurse notes that the patient skin color is bright red which action should the nurse take first
Insert two large - bore IV lines .
The patient has developed cardiogenic shock after a left anterior descending myocardial infection .Which circulatory - assist device should the nurse expect the patient to receive
Intraaortic balloon pump ( IABP )
The nurse is caring for a client admitted with cardiogenic shock . The client is experiencing chest pain and there is an order for the administration of morphine . In addition to pain control , what is the main rationale for administering morphine to this client ?
It dilates the blood vessels .
A client has experienced an electrical burn and has developed thick eschar over the burn site . Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound ?
Mafenide acetate cream
A patient is experiencing anaphylaxis . What medications would you expect the physician may order in a plan of care for anaphylaxis
Methylprednisolone Famotidine Epinephrine Albuterol
A client with burns to 40 % of the body arrives at the emergency room . Which prescriptions by the primary healthcare provider should the nurse anticipate in the emergent phase ? Select all that apply .
Monitoring the patient's temperature Administration of 100 % humidified oxygen Administration of lactated Ringer's intravenously Insertion of a nasogastric tube
A nurse is caring for a client newly diagnosed with acute myelogenous leukemia ( AML ) . Which assessment finding needs to be reported to the client's health care provider immediately ?
New onset of headache
The nurse is caring for a patient in septic shock who has received normal saline ( 3000 ml ) over the past hour . Presently the mean arterial pressure ( MAP ) is 40 mm Hg , hemoglobin 10 g / dl , and the urine output is 0.3 ml / kg / hr . What would the nurse expect the physician to order next ?
Norepinephrine IV drip
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes . Which action should the nurse take first ?
Notify the health care provider .
A patient is being cared for in the Neurological Care Unit following a spinal cord injury . Which of the following assessment findings indicate the patient may be experiencing neurogenic shock ?
Ob / HR : 48 bpm ; BP : 90/40 mm Hg .
When planning care for a patient on a mechanical ventilator , the application of positive end - expiratory pressure ( PEEP ) to the ventilator settings has which therapeutic effect ?
Prevention of alveolar collapse during expiration USAL
A patient in the compensatory stage of shock would most likely have which ABG ?
Respiratory alkalosis
The patient receives succinylcholine . What will be a priority assessment concern ?
Respiratory paralysis
A patient experiencing vasodilation , is diagnosed with circulatory ( distributive ) shock . The nurse will assess the patient for which etiologies ? Select all that apply .
Sepsis Anaphyaxis Spinal cord injury
The nurse is reviewing laboratory results on a patient who had a large burn 24 hours ago . Which result requires priority action by the nurse ?
Serum potassium of 6.1 mEq / L
A nurse is assessing a patient who is receiving a nitroglycerine Infusion to treat cardiogenic shock . Which finding indicates that the drug is effective ?
Skin is warm and pink
Esomeprazole is prescribed for a patient who incurred extensive burn injuries 5 days ago Which nursing assessment would best evaluate the effectiveness of the drug ?
Stool occult blood
Which patient is at greatest risk for ARDS ?
The 62 - year - old with COPD who is experiencing an exacerbation .
A patient who has septic shock is receiving a phenylephrine infusion through a right forearm IV . Which assessment finding obtained by the nurse indicates a need for immediate action ?
The patient's IV infusion site is cool and pale .
Prone positioning is being used for a patient with acute respiratory distress syndrome ( ARDS ) . Which information obtained by the nurse indicates that the positioning is effective ?
The patient's PaO₂ is 89 mm Hg , and the SaO2 is 91 % .
Eight hours after a thermal burn covering 50 % of a patient's total body surface area ( TBSA ) , the nurse assesses the patient . The patient weighs 92 kg ( 202.4 lb ) . Which information would be a priority to communicate to the health care provider ?
Urine output of 40 ml / hr for the past 2 hours
. A patient who has burns on the arms , legs , and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital action should the nurse take first ?
Use Use pulse oximetry to check oxygen saturation emergency room
A 26 year old patient receives the first dose of oxacillin IVPB and suddenly becomes restless . On further assessment the RN notes urticaria and wheezes . What medication do you expect the physician to order ?
a . Epinephrine IM
When admitting a patient with possible respiratory failure and high PaCO2 which assessment information should be immediately reported to the healthcare provider
a . The patient appears somnolent .
A patient with a diagnosis of septic shock has a lactic acid level of 7 mmol / L and fluid resuscitation has been initiated Which of the following indicates that the fluid resuscitation received by the patient is adequate ? (
a MAP of 70 mm Hg
A 70 year old patient is admitted to the emergency department after a car accident . It is suspected that the patient has internal bleeding his history of those that he has a history of hypertension diabetes seizure disorder in arthritis Dyamond reviews the patient medication list which medication is the most concerned with the iron my assistant a Compas Siri phase of shot
atenolol
A patient is being cared for in the Neurological Care Unit following a spinal cord injury Which of the following assessment findings indicate the patient may be experiencing neurogenic shock ?
b . HR : 48 bpm ; BP : 90/40 mm Hg
An older patient with cardiogenic systemic vascular resistance ( SVR ) . Which shock is cool and clammy Hemodynamic monitoring indicates a high intervention should the nurse anticipate ?
high Increase the rate for the nitroprusside infusion .
A patient with blunt trauma to the abdomen has received 3 L of normal saline . What is the most appropriate intervention in response to the following ABG : pH 7.21 , PaCO2 45 mmHg , PaO2 76 mmHg , HCO3 15 mEq ?
infuse Infuse a a unit of packed red blood cells ( PRBC )
A client with a respiratory problem is on a ventilator . The client's peak inspiratory pressures and spontaneous respiratory rate are increasing , and the PaO₂ is not improving . Using the SBAR ( Situation Background - Assessment - Recommendation ) technique for communication , the nurse calls the health care provider ( HCP ) . What recommendation should the nurse give to the HCP ?
initiating IV sedation .
