Unit 3- 2600
After an earthquake, four groups of clients are given different tags in accordance with the disaster triage tag system. What is the correct order of treatment priority for each group? 1. Group given red tags 2. Group given yellow tags 3. Group given green tags 4. Group given black tags
Red-Yellow-Green-Black
A nurse needs to administer fluid in a severely burned child of 2 years, but the peripheral vein is obscured. Which other route should the nurse use? 1 Intrathecal 2 Intraarterial 3 Intraosseous 4 Intraperitoneal
3 A nurse should use the intraosseous route for administering fluid if the peripheral vein is not accessible. Intrathecal administration is often associated with long-term medication administration through surgically implanted catheters. Intraarterial infusions are common in clients who have arterial clots. Chemotherapeutic agents, insulin, and antibiotics are administered by the intraperitoneal route. Hence, the nurse should not use these routes.
A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the rule of nines. Record your answer using one decimal place. _______%
The front of the head is 4.5%, and the anterior torso is 9%, for a total of 13.5%.
The nurse uses the Rule of Nines to estimate the percentage of the burn surface area on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the entire left leg. What is the percentage of burn injury for this client? Record your answer as a whole number. ________%
55 The Rule of Nines is used to determine the body surface area (BSA) of a burn injury. How the Rule of Nines estimates percent burn injury: 9% for the entire surface of one arm (a total of 9% x 2 for both arms); 18% for the posterior trunk, 1% for the genitals, and 18% for the entire left leg. Therefore, the percentage of body surface area sustaining a burn injury according to the Rule of Nines is: 9 + 9 + 18 + 1 + 18 = 55%.
The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing? 1 Bradypnea 2 Bradycardia 3 Hypotension 4 Hypothermia
4 After the removal of the burn client's clothing, the priority for the nurse is to monitor for hypothermia because burn trauma clients lose their ability to maintain body temperature due to the loss of skin which acts as an insulator. While the nurse will monitor for bradypnea, bradycardia, and hypotension, hypothermia is the priority.
A- Closed Femur fracture- Green B- Airway Obstruction- Red C- Closed Tibial Fracture-Black D- Open minor fracture with distal pulse- Yellow Triage officers are tagging clients with disaster triage tags at the site of an earthquake. Which client's tag requires replacement? A B C D
C Clients with closed fractures may be given green disaster triage tags. Therefore the black tag on client with a closed tibial fracture should be replaced with a green tag. The client with a closed femur fracture has correctly been given a green tag. Clients with life-threatening conditions such as airway obstruction or shock are applied with red disaster triage tags. Therefore, the client B is correctly given a red tag. Clients with open fractures with a distal pulse are given yellow tags. Therefore the client D is correctly tagged.
What is an example of third spacing in a burn injury? 1 Blister formation 2 Edema formation 3 Fluid mobilization 4 Fluid accumulation
1 Blister formation is an example of third spacing in burn injuries. Edema formation and fluid mobilization generally happen in every burn injury. Fluid accumulation is formed in second spacing in a burn injury.
A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. Which response by the nurse is most appropriate? 1 The epidermis is damaged. 2 The dermis is damaged partially. 3 The structures beneath the skin are destroyed. 4 Both the epidermis and the dermis are destroyed.
1 A damaged epidermis describes a superficial partial-thickness burn. The dermis is not damaged in superficial partial-thickness burns. The entire epidermis and part of the dermis are affected with deep partial-thickness burns. A destroyed epidermis and dermis describes full-thickness burns. Destroyed structures beneath the skin is too vague a description of what is involved.
The nurse is assessing four clients who were injured in a mass casualty event. Which client does the nurse plan to treat first according to the disaster triage tag system? 1 Client belonging to class I 2 Client belonging to class II 3 Client belonging to class III 4 Client belonging to class IV
1 Class I clients are emergent clients who are marked with red tag. These clients have an immediate threat to life and need attention first. Class II clients have major injuries and need treatment within 30 minutes to 2 hours. Class III clients have minor injuries and can be treated in a delayed manner. Class IV clients are those who are expected to die or are dead.
According to the disaster triage tag system, which color tag would the nurse feel is most suitable for a client who died in an earthquake? 1 Red 2 Black 3 Green 4 Yellow
2 Clients who are dead or are expected to die are issued a black tag according to the disaster triage tag system. A red tag is issued to the clients who have an immediate threat to life. A green tag is issued to the nonurgent or "walking wounded" clients. A yellow tag is issued to clients who can wait a short time to receive care.
What is a clinical manifestation of hypernatremia in burns? 1 Fatigue 2 Seizures 3 Paresthesias 4 Cardiac dysrhythmias
2 Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.
Which clients belong to class I according to the disaster triage tag system? A Clients who can wait a short time for treatment B Clients who are dead or expected to die C Clients who need emergency treatment D Clients who have no urgent need for treatment
C Emergent clients are identified with red tags and belong to class I according to the disaster triage tag system. Clients who can wait a short time for treatment are identified by yellow tags and belong to class II according to the disaster triage tag system. Clients who are expected to die or are dead are given a black tag and belong to class IV in the disaster triage tag system. Clients who have no urgency for treatment are issued green tags and belong to class III.
A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1 Crackles in the lungs 2 Decreased heart rate 3 Decreased blood pressure 4 Cyanosis
1 Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.
Which type of burn/injury may cause a client to have a cervical spine injury? 1 Electrical burns 2 Chemical burns 3 Inhalation injury 4 Cold thermal injury
1 Electrical burns may cause injuries to the cervical spine because intense electrical currents can fracture long bones and vertebrae. Chemical burns may cause eye and tissue damage. Inhalation injuries may damage the respiratory tract. Cold thermal injuries may cause tissue damage.
A client is considered to be in septic shock when what changes are assessed in the client's labwork? 1 Blood glucose is 70-100 mg/dL 2 An increased serum lactate level 3 An increased neutrophil level 4 A white blood count of 5000 cells/µL
2 The hallmark of sepsis is an increasing serum lactate level, a normal or low total WBC count > 12,000 cells/µL or < 4,000 cells/µL and a decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 and >150 mg/dL. Blood glucose levels of 70-100 mg/dL are considered normal.
A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply. 1 Soot on legs 2 Brassy cough 3 Deep breathing 4 Singed nasal hair 5 Dark mucous membranes
2 4 5 A brassy cough is indicative of possible pulmonary damage caused by an inhalation burn. Singed nasal hair indicates possible pulmonary damage. Dark mucous membranes are a sign of potential respiratory insufficiency that results from inhalation burns. Sputum will be sooty; sooty legs is not an indication. Deep breathing indicates metabolic acidosis, not respiratory insufficiency.
A client who experienced smoke inhalation has a negative chest x-ray and arterial blood gases that demonstrate PaO2 of 75 mm Hg, PaCO2 of 45 mm Hg, and pH of 7.35. Which intervention should the nurse anticipate will be prescribed by the healthcare provider? 1 Deep suctioning 2 Bronchodilators 3 Breathing exercises 4 Mechanical ventilation
3 Breathing exercises are needed. The client has hypoxemia; the expected range for PaO2 is 80 to 100 mm Hg. This intervention expands the alveoli, moves secretions toward the mouth to be expectorated, and increases the amount of oxygen that is delivered to alveolar capillary beds. Routine suctioning may injure already traumatized tissues and is contraindicated. Bronchodilators and mechanical ventilation are not indicated at this time based upon the x-ray results and PaCO2 and pH results.
A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained? 1 Flame burn 2 Chemical burn 3 Electrical burn 4 Radiation burn
3 In an electrical burn injury, changes in the ECG may indicate damage to the heart. In flame burn injuries, the smoldering clothing and all metal objects are removed. If a client suffers from chemical burns, the dried chemicals present on skin should not be made wet but should be brushed off. If the client has radiation burn injuries, then the source should be removed using tongs or lead protective gloves.
Which complication may be caused by sepsis in burns? 1 Diarrhea 2 Constipation 3 Paralytic ileus 4 Curling's ulcer
3 Paralytic ileus, or hypoactive bowel, is a complication caused by sepsis in clients with burns. Diarrhea can be caused by the use of enteral feedings or antibiotics. Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions. It is caused by a generalized stress response to decreased blood flow to the gastrointentinal tract in clients with burns.
A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed? 1 Assessing for crepitus 2 Assessing for bleeding 3 Maintaining a patent airway 4 Performing neurologic assessment
3 The nurse should assess, ensure, and maintain a patent airway first in a client with neck trauma. The nurse then may palpate the skin near the esophagus to assess crepitus, which indicates an injury to the esophagus. After ensuring airway patency, the nurse should assess for bleeding or impending shock. The nurse should also perform a neurologic assessment for mental status, sensory level, and motor function, which holds a medium priority.
After a hurricane, the nurse is assessing the response of a client to stimuli on the Glasgow Coma Scale (GCS) as a part of the primary survey. The nurse observes that the client opens his eyes when his name is stated, uses disorganized words, and is unable to follow commands, but attempts to remove the offending stimulus. What is the Glasgow coma score for this client? Record your answer using a whole number.____________
11 Glasgow scale (GCS) is used by the nurse to conduct neurologic assessment as a part of primary survey. It is performed to determine the client's response to verbal and/or painful stimuli in order to assess the level of consciousness and degree of disability. A score of 3 is given when the client opens the eyes when the name is stated. If disorganized use of words is present, a score of 3 is given. A score of 5 is given when there is a lack of obedience but attempts to remove the offending stimulus. Therefore the client's GCS score would be 3+3+5= 11.
The nurse is caring for a client with burns receiving opioid analgesics and who is sedated. Which medications should the nurse anticipate to be prescribed by the primary healthcare provider to overcome this side effect of the opioid analgesics? Select all that apply. 1 Morphine 2 Pregabalin 3 Lorazepam 4 Midazolam 5 Gabapentin
2 5 Pregabalin and gabapentin are adjuvant analgesics used to overcome the side effects caused by opioid analgesics. Morphine is an opioid analgesic used in the treatment of pain that can cause sedation. Lorazepam and midazolam are anxiolytic agents used to inhibit anxiety.
A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall? 1 Partial-thickness burns require grafting before they can heal. 2 Partial-thickness burns are often painful, reddened, and have blisters. 3 Partial-thickness burns cause destruction of both the epidermis and dermis. 4 Partial-thickness burns often take months of extensive treatment before healing.
2 Pain is from the loss of the protective covering of the nerve endings; blisters and redness occur because of the injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only the epidermis and only part of the dermis. Recovery from partial-thickness burns with no infection occurs in 2 to 6 weeks.
A nurse is planning care to prevent deformities and contractures in a client with burns. When will the nurse begin range-of-motion (ROM) exercises? 1 When pain has lessened 2 When vital signs are stable 3 When skin grafts are healed 4 When emotional status stabilizes
2 ROM exercises should be instituted as soon as it will not compromise the individual's cardiopulmonary status. Pain will continue for some time, and if ROM exercises are delayed until it subsides, contractures will develop. If ROM exercises are delayed until skin grafts heal, contractures will develop. Pain and inability to cope may be prolonged; if ROM exercises are delayed, contractures will develop.
The nurse is conducting a primary survey during the emergency assessment. Which nursing actions are appropriate during the airway assessment? Select all that apply. 1 Assessing for edema 2 Counting respiratory rate 3 Checking for foreign bodies 4 Noting use of accessory muscles 5 Monitoring for respiratory distress
1 3 5 Nursing actions that are appropriate when conducting a primary survey during the airway assessment include assessing for edema, checking for foreign bodies, and monitoring for respiratory distress. Counting the respiratory rate and noting use of accessory muscles are nursing actions appropriate during the breathing assessment.
Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma client with a penetrating wound? Select all that apply. 1 Documenting the client's care 2 Formulating the client's plan of care 3 Reassessing the client's level of consciousness 4 Administering tetanus prophylaxis to the client 5 Transferring the client to the general medical unit
1 4 The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all client care and administering tetanus prophylaxis. Formulating the client's plan of care, reassessing level of consciousness, and transferring the client to the general medical unit are nursing actions implemented once the client is stable.
When changing the dressings on deep partial-thickness burns on a client's hand, the nurse should use which type of gauze and which technique? 1 Cotton-backed; fully extending the fingers with thumb in opposition 2 Non-cotton-backed; placing a hand roll with fingers slightly flexed 3 Non-cotton-backed; extending fingers fully with gauze between each finger 4 Cotton-backed; a hand roll, with fingers completely flexed and thumb in opposition
2 Non-cotton-backed gauze is less apt to adhere to the wound than cotton-backed gauze; the hands should be maintained in an anatomic position of slight flexion with each finger separated. Cotton-filled or cotton-backed gauze should not be used because it may adhere to the wound; the hands should be in anatomic position with fingers slightly flexed. The hands should not be positioned anatomically in full extension or full flexion; the hands should be slightly flexed in functional alignment.
What are the steps of performing a primary survey according to priority to assess a client with severe injuries from a bomb blast? Correct 1. Airway 2. Breathing 3. Circulation 4. Disability 5. Exposure
ABCDE The initial assessment of a client with severe injuries in a bomb blast is called the primary survey. It is based on a standard "ABC" mnemonic plus a "D" and "E." Here, A stands for airway/cervical spine, B for breathing, C for circulation, D for disability, and E for exposure.
A nurse is assessing an adolescent after the administration of epinephrine. What side effect is most important for the nurse to identify? 1 Tachycardia 2 Hypoglycemia 3 Constricted pupils 4 Decreased blood pressure
1 Epinephrine is a sympathetic nervous system stimulant that causes tachycardia. Hyperglycemia, not hypoglycemia, may result. The pupils will be dilated, not constricted. Epinephrine is more likely to cause hypertension than hypotension.
Which tag color according to the disaster triage tag system is assigned to a client who has an immediate threat to life? 1 Red tag 2 Black tag 3 Green tag 4 Yellow tag
1 According to the disaster triage tag system, a red colored tag is used for a client who has an immediate threat to life. A black colored tag is used for a client who is expected to die or is dead. Green colored tags are used for a client who has minor injuries. A yellow colored tag is used for a client who has major injuries and is requiring immediate treatment.
The registered nurse is teaching a student nurse about the disaster triage tag system. Which statement made by the student nurse indicates ineffective learning? 1 "I will use a yellow tag for clients with shock." 2 "I will use a green tag for clients with closed fractures." 3 "I will use a red tag for clients with airway obstruction." 4 "I will use a black tag for clients with massive head trauma."
1 According to the disaster triage tag system, a yellow tag is used for clients who require treatment within 30 minutes to 2 hours. Clients with shock require immediate attention and a red tag is appropriate. A green tag is used in clients with minor injuries, such as fractures and abrasions, who can be managed with delayed treatment. A red tag is used for the clients who have immediate threats to life, such as an airway obstruction. A black tag is used for clients who are expected to die or require mechanical ventilation in conditions such as massive head trauma and high cervical spinal cord injury.
The nurse is performing resuscitation interventions for airway, breathing, and circulation as part of a primary survey in a client. Which order of actions should the nurse follow for this client? 1. Establish airway by positioning, suctioning, and oxygen as needed. 2. Assess breath sounds and respiratory effort. 3. Prepare for chest decompression if needed. 4. Maintain vascular access using a large-bore catheter. 5. Use direct pressure for external bleeding.
The primary survey includes assessment of airway/cervical spine, breathing, circulation, disability, and exposure. First, the nurse should establish airway patency by positioning, suctioning, and providing oxygen as needed. Assess breath sounds and respiratory effort and provide chest decompression if needed in order to assess breathing. Maintain vascular access using a large-bore catheter and use direct pressure for any external bleeding.
A 7-year-old child survives a near-drowning episode in a cold pond. What factor does the nurse identify that will have the greatest effect on the child's prognosis? 1 Hypoxia 2 Hyperthermia 3 Emotional trauma 4 Aspiration pneumonia
1 The degree of hypoxia experienced by the child will determine the extent of neurological, liver, and renal damage. The child was hypothermic, not hyperthermic. Although emotional trauma can be overwhelming, it usually does not influence the ultimate physical prognosis as the extent of the hypoxia does. Although aspiration pneumonia may be severe initially, it does not result in long-term sequelae as hypoxia can.
A 12-year-old child has just received a dose of epinephrine. What is the priority assessment after this medication is administered? 1 Tachycardia 2 Hypoglycemia 3 Constricted pupils 4 Decreased blood pressure
1 Epinephrine is a sympathetic nervous system stimulant that causes tachycardia. Hyperglycemia, not hypoglycemia, may result. The pupils will dilate, not constrict. Epinephrine is more likely to cause hypertension than hypotension because of its effect of peripheral vasoconstriction.
Which is the priority nursing action when providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale of 7? 1 Preparing for intubation 2 Observing for chest wall trauma 3 Covering the client with a blanket 4 Applying direct pressure to the client's wound
1 If the Glasgow Coma Scale (GCS) score is 8 or less, the priority action by the nurse is to prepare for endotracheal intubation because the client is at risk for airway compromise. Observing for chest wall trauma, covering the client with a blanket, and applying direct pressure to a bleeding wound are all appropriate actions but not the priority.
The nurse is advising a client to carry a prescription of epinephrine autoinjector. Which insect bite or sting is responsible for the nurse providing this advice? 1 Wasp 2 Scorpions 3 Black widow spider 4 Brown recluse spider
1 If the client has allergic reaction to bee or wasp stings, the nurse should advise the client to carry an epinephrine autoinjector for emergencies. For scorpion stings, providing supplemental oxygen and IV fluid replacement immediately can act as emergency measures. The priority intervention for a black widow spider bite in a prehospital setting is to apply an ice pack because cold application decreases the action of the neurotoxin. In case of brown recluse spider bite, the application of an ice pack also decreases the action of the neurotoxin.
A client is admitted after incurring electrical burns to both hands while playing golf during a lightning storm. The nurse is assessing the entrance and exit wounds. Which information should the nurse consider about electrical burns? 1 Causes severe nervous tissue destruction along a path of least resistance 2 Results in severe tissue destruction when the burn is incurred by direct current 3 Causes a line of destruction beginning at the grounding point to the point of contact 4 Results in visible dermal wounds that denote the internal electrical current destruction
1 Nerves and blood vessels are the least resistant tissues. Electrical current flows from the point of contact to the point of grounding. It is difficult to track the path of electricity by external visualization; it often requires more extensive diagnostic exploration.
A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L (135 mmol/L) and the potassium level is 3.0 mEq/L (3.0 mmol/L). The nurse notifies the primary healthcare provider. Which prescription should the nurse be prepared to administer? 1 Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution. 2 Add sodium chloride (NaCl) to the existing IV lactated Ringer solution. 3 Discontinue the IV NaCl with 20 mEq KCl solution and replace with IV 5% D5W solution. 4 Discontinue the IV 5% D5W with 40 mEq KCl solution and replace with IV 5% D5W solution.
1 Silver nitrate can precipitate electrolyte imbalances; the client's potassium is below the expected range of 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L) and should be supplemented by adding potassium chloride to the IV. The client's sodium level is within the expected range of 135 to 145 mEq/L (135 to 145 mmol/L); additional sodium chloride is not needed. Discontinuing the IV NaCl with 20 mEq KCl solution and replacing it with IV 5% D5W solution and discontinuing the IV 5% D5W with 40 mEq KCl solution and replacing it with IV 5% D5W solution will cause a further depletion of potassium.
The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? 1 Determining drug allergies 2 Noting the general appearance 3 Examining the neck for stiffness 4 Auscultating for heart and lung sounds
1 The priority nursing action during the health history portion of the assessment is to determine drug allergies. Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history.
The nurse is conducting a primary survey during an emergency assessment. Which are the priority nursing actions related to breathing in response to this assessment? Select all that apply. 1 Having suction available 2 Giving supplemental oxygen 3 Assessing pupil size and reactivity 4 Immobilizing any obvious deformities 5 Obtaining blood samples for type and crossmatch
1 2 The priority nursing actions related to breathing when conducting a primary survey during an emergency assessment include having suction available and giving supplemental oxygen. Assessing pupil size and reactivity is an appropriate nursing action during the brief neurologic assessment. Immobilization of any obvious deformities is a nursing action appropriate in response to data obtained during the disability portion of the assessment. Obtaining blood samples for a type and crossmatch is a nursing action appropriate in response to data obtained during the circulation portion of the assessment.
The healthcare team is caring for clients in an emergency department according to the five-level triage system. In what order should the clients receive care? 1. Client with cardiac arrest 2. Client with chest pain due to ischemia 3. Client with a hip fracture 4. Client with minor burns
1 2 3 4 Clients with life-threatening complications such as cardiac arrest are triaged as an emergency severity index one (ESI-1) which requires immediate care. Clients with chest pain due to ischemia are triaged as an ESI-2, which requires treatment within 10 minutes. Clients with hip fractures should be treated within an hour. Care for a client with minor burns can be delayed because this is not a life-threatening condition.
A client who sustained serious burns now has a stress ulcer. Which clinical indicators of shock should the nurse immediately report to the primary healthcare provider? Select all that apply. 1 Weakness 2 Diaphoresis 3 Tachycardia 4 Cold extremities 5 Flushed skin tone
1 2 3 4 The stress ulcer can bleed, leading to shock. Weakness is related to the decrease in the oxygen-carrying capacity of the blood associated with shock. Diaphoresis and tachycardia are sympathetic nervous system responses associated with shock. Peripheral vasoconstriction is associated with the sympathetic nervous system response associated with shock and leads to cold extremities. The skin will be pale, rather than flushed, because of peripheral vasoconstriction.
A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation? 1. Using a jaw-thrust maneuver to establish an airway 2. Providing bag-valve-mask (BVM) ventilation 3. Palpating for the presence of a radial pulse 4. Monitoring systolic blood pressure 5. Assessing the score of eye opening 6. Removing the clothing with scissors
1 2 3 4 5 6 A client with trauma should be assessed for airway, breathing, circulation, disability, and exposure. A jaw-thrust maneuver helps to establish an airway and breathing, and bag-valve-mask (BVM) ventilation with 100 percent oxygen source ensures ventilatory assistance. Following respiratory assessment is the circulation assessment. The pulse of the client is palpated at the radial, femoral, and carotid areas, and the systolic blood pressure is monitored. Disability is assessed using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. The clothes of the client are removed with scissors to prevent fabric melting into the skin.
What actions should the nurse take when a client develops an anaphylactic reaction? Select all that apply. 1 Apply oxygen at 90 to 100% 2 Call the Rapid Response Team 3 Elevate the head of the bed to 45 degrees 4 Assign a nursing assistant to stay with the client 5 Ensure emergency airway equipment is at the bedside
1 2 3 5 Emergency care of the client with anaphylaxis includes applying oxygen at 90 to 100%, calling the Rapid Response Team, elevating the head of the bed to 45 degrees, and ensuring that emergency airway equipment is at the bedside. The nurse should stay with the client because the client is acutely ill and may need immediate emergency interventions that are beyond the scope of a nursing assistant's practice.
The nurse is caring for a client admitted with fluid overload. Which tasks are most appropriate to be delegated to the patient care associate? Select all that apply. 1 Documenting vital signs 2 Documenting urine output 3 Assessing the laboratory findings 4 Administering diuretic intravenously 5 Repositioning the client every one or two hours
1 2 5 Patient care associates are unlicensed assistive personnel whose scope of practice includes documenting vital signs and urine output and repositioning the client every one or two hours. Assessing the laboratory findings should be carried out by the registered nurse only. Intravenous medications should be administered the registered nurse. Administration of oral and topical medications can be delegated to the licensed practical or vocational nurse.
Which are the highest priorities when conducting a primary client survey during the emergency assessment? Select all that apply. 1 Airway 2 Disability 3 Breathing 4 Circulation 5 Cervical spine
1 5 Airway and stabilization of the cervical spine are the top priorities when conducting a primary client survey during the emergency assessment. The nurse will then focus on breathing, circulation, and disability.
A toddler with a puncture wound to the sole is brought to the emergency department. Because of a language barrier the caregiver cannot provide a clear history of previous tetanus immunizations. Tetanus immunoglobulin (TIG) is prescribed by the healthcare provider. The nurse explains to the caregiver that this medication is given because it has what action? 1 Produces lifelong passive immunity to tetanus 2 Confers short-term passive defense against tetanus 3 Induces long-lasting active protection from tetanus 4 Stimulates the production of antibodies to fight tetanus
2 Tetanus immunoglobulin contains antibodies, not the live or attenuated virus; it confers short-term passive immunity that is temporary. Tetanus toxoid, not TIG, stimulates the production of antibodies.
The registered nurse is teaching a student nurse about the ongoing monitoring of a client with electrical burns. Which statement made by the student nurse indicates the need for further teaching? 1 "I should monitor the airway." 2 "I should monitor the eye pH." 3 "I should monitor vital signs." 4 "I should monitor urine output."
2 The pH of the eye is monitored when chemical burns occur to the eye. The nurse should monitor the airway for breathing, vital signs, heart rhythm, neurovascular status of injured limbs, level of consciousness, and urine output.
A client with third-degree burns asks a nurse, "Why do I need a temporary pigskin graft?" What is the nurse's best response? 1 "It helps debride necrotic tissue." 2 "It promotes rapid healing of the wound." 3 "When sutured in place, it provides better adherence." 4 "Topical lotions can be used concurrently with the graft."
2 The graft provides a framework for granulation and speeds healing. The graft promotes epithelialization; enzymatic preparations or surgery may be used to debride the burned tissue. Pigskin grafts are not sutured. Using topical lotions on burn wounds can increase the likelihood of infections.
Four near-drowning victims are admitted to the emergency department. Which victim does the nurse determine to be at greatest risk for hypovolemia? 1 72-year-old rescued from a lake 2 50-year-old rescued from the ocean 3 17-year-old rescued from a backyard pool 4 2-year-old rescued from a bathtub
2 The high osmotic pressure of the saltwater from the ocean draws fluid from the vascular space into the alveoli, causing hypovolemia. The others involve aspiration of freshwater, which causes fluid to move rapidly into the capillary bed and circulation, leading to fluid overload. A lake, backyard pool, and bathtub don't use saltwater, so there is less risk.
The primary healthcare provider instructs the nurse to place a client with burns in the supine position with the affected arm over the head to reduce the risk of contractures. Which part of the client is affected due to burns? 1 Wrist 2 Lateral trunk 3 Anterior shoulder 4 Posterior shoulder
2 A client whose lateral trunk is affected due to burns should be placed in supine position with the affected arm over the head to reduce the risk of contractures. A client whose wrist is affected should use a splint. The nurse should maintain the upper arm at 90 degrees of abduction from the lateral aspect of the trunk of a client whose anterior shoulder is affected. The nurse should keep the arm slightly behind the midline of a client whose posterior shoulder is affected.
A 15-year-old adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. What are the purposes of administering pain medication by way of the intravenous route rather than the intramuscular route? Select all that apply. 1 Adolescents are afraid of injections. 2 It decreases the risk of tissue irritation. 3 Severe pain is reduced more effectively. 4 Impaired peripheral circulation is bypassed. 5 It provides for more prolonged relief of pain.
2 3 4 Decreasing the risk for tissue irritation can reduce the risk of infection, which is also one of the top care priorities after a burn injury. The medication begins to work in minutes; doses can be controlled. Intramuscular medications are avoided when possible to prevent inadequate absorption of the medication because of damaged tissue. Stating that adolescents are afraid of injections is a generalization that is not necessarily true. The duration of effectiveness of an analgesic is based on its therapeutic level in the body, regardless of what route is used.
Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1 Inserting a nasogastric tube 2 Immobilizing the cervical spine 3 Arranging for diagnostic studies 4 Preparing for chest tube insertion 5 Applying direct pressure to a wound
2 4 5 The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound. The secondary survey begins after addressing each step of the primary survey and starting any lifesaving interventions. The secondary survey is a brief, systematic process that aims to identify all injuries. Nursing actions appropriate during the secondary, not primary, survey include inserting a nasogastric tube and arranging for diagnostic studies.
A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. What should the nurse assess for in this client? 1 Dehydration 2 Dry brittle hair 3 Prolonged wound healing 4 Clubbing of the fingertips
3 Adequate intake of protein, carbohydrates, vitamin C, and minerals is necessary for tissue building and wound healing. There are no data to indicate dehydration; although the client is not eating, the client may be drinking fluids. Dry brittle hair will take a prolonged period of time; it will not occur during a short period. Clubbing of the fingertips is associated with prolonged hypoxia.
A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching? 1 "Type I immune response to latex has an immediate onset." 2 "Type I immune reaction to latex leads to release of IgE antibodies." 3 "The client's first exposure to latex will cause a type IV allergic reaction." 4 "Type IV immune response to latex occurs after 12 to 48 hours after exposure."
3 Both type I and type IV hypersensitive reactions require prior exposure to cause an immune response in a subsequent exposure. The most immediate immune response is a type I reaction, in which the body produces IgE antibodies against the allergen. A type IV immune response occurs 12 to 48 hours after the exposure to the allergen and is referred to as a delayed hypersensitivity response.
A 10-year-old child who was rescued from a house fire is brought to the emergency department with burns of the extremities. During assessment of the child, what finding is of most concern to the nurse? 1 Increased temperature 2 Increasing activity level 3 Burns around the mouth 4 Edema distal to the burns
3 Burns around the mouth indicate that the child may have inhalation burns; respiratory tract injury may result in edema, causing an airway obstruction. An increase in temperature indicates the presence of an infection; it is too early for an infection to occur. Increased activity is promising because it indicates that the burns were not severe. Edema distal to burns of the extremities is an expected finding.
Which statement by the nurse is true regarding the disaster triage tag system? 1 Class IV clients are issued a red tag. 2 Class III clients are given a black tag. 3 Class II clients are marked with a yellow tag. 4 Class I clients are identified with a green tag.
3 Class II clients who can wait for a short time for care are marked with a yellow tag. Class IV clients who are expected to die or are dead are issued a black tag. Class III clients who require nonurgent care or "walking wounded" are given a green tag. Class I clients who require emergency care are identified with a red tag.
A- waxy, white, darkbrown appearance B- redness, pain, minimal edema C-mostly blebs, blisters, severe pain D- dry, leathery eschar, no pain The nurse is examining four different clients who present with thermal burns. Which client does the nurse diagnose as having second-degree burns? 1 Client A 2 Client B 3 Client C 4 Client D
3 Client C has second-degree burns. The client is experiencing severe pain and the skin shows moist blebs and blisters. Client A may have third- and fourth-degree burns, in which the skin is waxy white, dark brown in appearance. Client B may have first-degree burns, in which the skin is red in color with minimal edema and pain. Client D may have third- and fourth-degree burns as the skin is dry, leathery eschar and there is absence of pain.
A- Open Fractures B- Airway obstruction C- Sprain D- Shock The registered nurse is teaching a student nurse about the disaster triage tag system. The nurse provides details of our clients along with their conditions for identification. Which statement made by the student nurse indicates effective learning? 1 "I would issue a red tag to client A." 2 "I would issue a black tag to client B." 3 "I would issue a green tag to client C." 4 "I would issue a yellow tag to client D."
3 Client C with a sprain, which is a minor injury that does not require immediate treatment, should be given a green tag according to the triage tag system. Client A with open fractures that are due to a major injury should be given a yellow tag according to the triage tag system. Client B with airway obstruction has an immediate threat to life and should be given a red tag according to the triage tag system. Client D with shock has an immediate threat to life and should be given a red tag according to the triage tag system.
A- Massive Head Injury- Red B- Compound fracture- Green C- 90% full thickness burns- Black D- Skin lacerations- Yellow The nurse is triaging clients who have arrived at the hospital after a large-scale disaster. Based on the data in the table, which client is appropriately tagged according to the disaster triage tag system? 1 Client A 2 Client B 3 Client C 4 Client D
3 Clients who are expected to die are issued black tags. Client C with full-thickness burns is triaged into the expectant category and would be given a black tag. Clients who require immediate treatment are issued red tags. Client A with a massive head injury would likely be triaged into the expectant category and would be given a black tag, not a red tag. A yellow tag is issued to clients with major injuries such as compound fractures. So, client B with a compound fracture should be given a yellow tag. Green tags are issued to clients with minor injuries. So, client D with skin lacerations should be issued a green tag.
Which color tagged clients usually make up the greatest number in most large-scale multi-casualty situations, based on the disaster triage tag system? 1 Red 2 Black 3 Green 4 Yellow
3 Green-tags clients usually make up the greatest number in most large-scale multi-casualty situations. These clients have minor injuries and they may actually evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries. Clients belonging to these three categories usually do not make up the greatest number in most large-scale multi-casualty situations.
The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. What type of respirations does the nurse expect the client to exhibit? 1 Dyspnea 2 Hyperpnea 3 Kussmaul breathing 4 Cheyne-Stokes breathing
3 Kussmaul breathing is an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide. Dyspnea is difficult breathing associated with subjective or objective distress in response to oxygen problems. Hyperpnea is a deep, rapid rate of breathing without a subjective sense of extra effort, usually as a response to strenuous effort. Cheyne-Stokes respirations are characterized by a waxing and waning of breathing that is usually associated with pathology of the respiratory center in the brain.
Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do? 1 Give the client orange juice by mouth. 2 Increase the client's intravenous (IV) flow rate. 3 Moisten the client's lips with a wet 4 × 4 gauze. 4 Offer the client 4 oz (120 mL) of water by mouth.
3 No bowel sounds are present; therefore, the client must remain NPO. Comfort measures may be helpful until bowel sounds return and the primary healthcare provider changes the dietary prescription. Giving the client orange juice or offering 4 oz (120 mL) of water by mouth is unsafe; the client must be kept NPO until bowel sounds are present. The urinary output is adequate; there is no need to increase IV fluids. Also, the nurse cannot increase the IV flow rate without a primary healthcare provider's prescription.
What is the mechanism of action of norepinephrine in managing anaphylaxis? 1 Norepinephrine blocks the effects of histamine 2 Norepinephrine inhibits the degranulation of mast cells 3 Norepinephrine increases blood pressure and cardiac output 4 Norepinephrine rapidly stimulates alpha- and beta-adrenergic receptors
3 Norepinephrine is a vasopressor that elevates the blood pressure and cardiac output in clients suffering from anaphylactic reactions. Diphenhydramine HCL blocks the effects of histamine on various organs. Corticosteroids such as dexamethasone prevent the degranulation of mast cells. Epinephrine works by rapidly stimulating alpha- and beta-adrenergic receptors.
n the immediate period after admission to the burn unit with severe burns, a 5-year-old child requests a drink of milk. What is the most appropriate nursing intervention? 1 Giving ice chips as desired 2 Permitting milk if it has been iced 3 Maintaining NPO status for 24 to 48 hours 4 Limiting oral fluid to 15 mL every 4 hours
3 Nothing-by-mouth (NPO) status is maintained during the early emergency/resuscitative phase because of the probability of paralytic ileus. It is unsafe to offer ice chips because the fluid that is ingested interferes with monitoring and control of the child's fluid and electrolyte status. It is unsafe to offer oral fluids, not only because of the danger of paralytic ileus but also because they interfere with monitoring and control of the child's fluid and electrolyte status.
During a parenting class a nurse is discussing infant/toddler nutrition and ways to reduce the risk of food allergies. What food item should the nurse recommend that the parents avoid until their children are 3 years old? 1 Cow's milk 2 Soy products 3 Peanut butter 4 Chocolate candy
3 Peanut allergies tend to be very severe. To reduce the risk of peanut allergies, parents should delay their introduction into the diet until the gastrointestinal tract has matured. Cow's milk is introduced after 1 year. Although often considered hypoallergenic, soy products can cause food allergies. However, because of the infrequency of soy in the American diet, its entry is not delayed after the first year. Chocolate may be introduced after the first year of life.
To prevent septic shock in the hospitalized client, what should the nurse do? 1 Maintain the client in a normothermic state. 2 Administer blood products to replace fluid losses. 3 Use aseptic technique during all invasive procedures. 4 Keep the critically ill client immobilized to reduce metabolic demands.
3 Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.
A client who is recovering from deep partial-thickness burns develops chills, fever, flank pain, and malaise. The primary healthcare provider makes a tentative diagnosis of urinary tract infection. Which diagnostic tests should the nurse expect the primary healthcare provider to prescribe to confirm this diagnosis? 1 Cystoscopy and bilirubin level 2 Specific gravity and pH of the urine 3 Urinalysis and urine culture and sensitivity 4 Creatinine clearance and albumin/globulin (A/G) ratio
3 The client's manifestations may indicate a urinary tract infection; a culture of the urine will identify the microorganism, and sensitivity will identify the most appropriate antibiotic. A cystoscopy is too invasive as a screening procedure; altered bilirubin results indicate liver or biliary problems, not urinary signs and symptoms. Creatinine clearance reflects renal function; A/G ratio reflects liver function. Although an increased urine specific gravity may indicate red blood cells (RBCs), white blood cells (WBCs), or casts in the urine, which are associated with urinary tract infection, it will not identify the causative organism.
A 4-year-old child who barely survived a near-drowning episode is in critical condition in the pediatric intensive care unit. Suddenly the child opens her eyes and smiles, prompting a parent to say to the nurse, "Look! I think she'll get better now." What is the best response by the nurse? 1 "You're right; that's a very good sign." 2 "Try to have your child hold your hand." 3 "We're doing everything we can to promote recovery." 4 "God certainly must be watching over your child today."
3 The nurse must emphasize that everything possible is being done because the outcome cannot be predicted at this time. Encouraging the parent's positive interpretation of the child's reflexive behavior raises false hope. Telling the parent that God is watching over the child constitutes false hope. The parent's statement did not ask for the nurse's religious viewpoint; if the child does not improve, the parent may then perceive that God is not watching over the child.
A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? 1 Decreased rate of glomerular filtration 2 Excessive blood loss through the burned tissues 3 Plasma proteins moving out of the intravascular compartment 4 Sodium retention occurring as a result of the aldosterone mechanism
3 The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.
Which client conditions require the nurse to tag with red according to the disaster triage tag system? Select all that apply. 1 Sprains 2 Abrasions 3 Hemorrhage 4 Airway obstruction 5 Compound fracture
3 4 The clients with conditions such as airway obstruction need immediate emergency care. According to the disaster triage tag system, these clients are issued a red tag. A hemorrhage needs immediate care as this is potentially life-threatening and these clients are also issued a red tag. Sprains and abrasions are minor injuries and do not require immediate care. Clients with such conditions are issued a green tag. Compound fractures are major injuries that require treatment and these clients will be issued a yellow tag.
After providing epinephrine to a client experiencing an anaphylactic reaction, which second-line drugs should the nurse prepare to provide? Select all that apply. 1 Dopamine 2 Norepinephrine 3 Dexamethasone 4 Diphenhydramine hydrochloride 5 Hydrocortisone sodium succinate
3 4 5 Dexamethasone is a corticosteroid that is a second-line drug used in the treatment of anaphylaxis. Diphenhydramine hydrochloride is an antihistamine that is a second-line drug used in the treatment of anaphylaxis. Hydrocortisone sodium succinate is a corticosteroid that is a second-line drug used in the treatment of anaphylaxis. Dopamine and norepinephrine are vasopressor medications and are considered support drugs in the treatment of anaphylaxis.
Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? 1 Urticaria 2 Tachycardia 3 Restlessness 4 Laryngeal edema
4 Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention. The reaction may also involve symptoms of irritability, cutaneous signs of urticaria, tachycardia, and increasing restlessness, but these are not as life threatening as laryngeal edema. Ensuring an open airway is priority.
A client is admitted with traumatic injuries after a tornado. While performing resuscitation during the primary survey, the nurse notices a compromised airway. Which nursing intervention would be of most benefit to the client? 1 Preparing for chest decompression if needed 2 Monitoring vital signs, especially blood pressure and pulse 3 Preventing hypothermia using blankets and heating devices 4 Preparing for endotracheal intubation and mechanical ventilation
4 Preparing for endotracheal intubation and mechanical ventilation ensures airway patency during the primary survey in order to reduce the severity of airway compromise. Preparing for chest decompression is done during the primary survey when there are no breath sounds. Monitoring vital signs, especially blood pressure and pulse, is performed to assess circulatory disorders. Preventing hypothermia using blankets and heating devices is done during the exposure assessment.
A client is admitted with severe burns, is obese, and has pre-existing respiratory problems. Which complication should the nurse anticipate? 1 Necrosis 2 Pneumonia 3 Dysrhythmias 4 Venous thromboembolism
4 Venous thromboembolism is the complication of the client with severe burns, who is obese and has pre-existing respiratory problems. Necrosis is an untreated complication of the cardiovascular system. Pneumonia is a complication for the client with pre-existing respiratory problems. Dysrhythmias are a complication of the cardiovascular system.
A client is admitted for treatment of partial- and full-thickness burns of the entire right lower leg extremity and the anterior portion of the right upper arm. A nurse performs an immediate appraisal of the percentage of body surface area burned using the rule of nines. What percentage of body surface area does the nurse determine is affected? Record the answer to one decimal place. _______%
The entire right lower extremity is 18%; the anterior portion of the right upper extremity is 4.5%. 18 + 4.5 = 22.5.
