CC Exam 4

A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this diagnosis? (Select all that apply.) a. Epigastric and abdominal pain b. Nausea and vomiting c. Diaphoresis d. Jaundice e. Hyperactive bowel sounds f. Fever

A,B,D,F Clinical manifestations of acute pancreatitis include pain, vomiting, nausea, fever, abdominal distention, abdominal guarding, abdominal tympany, hypoactive or absent bowel sounds, severe disease, peritoneal signs, ascites, jaundice, palpable abdominal mass, Grey Turner sign, Cullen sign, and signs of hypovolemic shock. There may be peritonitis involved with pancreatitis and percussion will reveal a tympanic abdomen; bowel sounds will be decreased or absent

A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? a. Escharotomy b. Silver Sulfadiazine application c. Splint application d. Xenograft application

ANS: A An escharotomy may be required to restore arterial circulation and to allow for further swelling. The escharotomy can be performed at the bedside with a sterile field and scalpel.

Which pathophysiologic mechanism occurs in the patient with type 2 diabetes? a. Lack of insulin production and excessive glucose intake b. Decreased insulin secretion and insulin resistance c. Overproduction of glucose and decreased metabolism d. Increased uptake and decreased release of glucose in the cells

ANS: B Type 2 diabetes is identified by decreased insulin secretion and insulin resistance, with a relative, versus absolute, insulin deficiency.

Which nursing intervention should be initiated on all patients with the syndrome of inappropriate antidiuretic hormone (SIADH)? a. Placing the patient on an air mattress b. Encouraging oral fluids c. Initiating seizure precautions d. Applying soft restraints

ANS: C Excessive ADH dramatically alters the sodium balance in the extracellular vascular compartment. The overhydration causes a dilutional hyponatremia and reduces the sodium concentration to critically low levels. Patients with severe hyponatremia (less than 125 mEq/L serum sodium) experience severe neurologic symptoms including seizures

What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.

ANS: C Negative interstitial hydrostatic pressure represents an edema-generating mechanism and occurs for approximately 2 hours after injury. Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space. Plasma is then further diluted with fluid resuscitation. Thus, osmotic pressure is decreased and further fluid extravasation can occur.

A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms? a. Metabolic acidosis and hypovolemia b. Decreasing hemoglobin and hematocrit c. Hyperkalemia and hypernatremia d. Hematemesis and melena

ANS: D The initial clinical presentation of the patient with acute gastrointestinal (GI) hemorrhage is that of a patient in hypovolemic shock; the clinical presentation depends on the amount of blood lost. Hematemesis (bright red or brown, coffee grounds emesis), hematochezia (bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care? a. Monitor the patient for hypovolemic shock from plasma volume depletion. b. Observe the patient for hypoglycemia and hypercalcemia. c. Initiate enteral feedings after the nasogastric tube is placed. d. Place the patient on a fluid restriction to avoid the fluid sequestration.

ANS: A Because pancreatitis is often associated with massive fluid shifts, intravenous crystalloids and colloids are administered immediately to prevent hypovolemic shock and maintain hemodynamic stability. Electrolytes are monitored closely, and abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected. If hyperglycemia develops, exogenous insulin may be required.

What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure

ANS: A Inhalation injuries have emerged as the most common cause of death in burn patients, whereas 40 to 50 years ago, burn shock followed by burn sepsis accounted for most burn-related deaths

A patient is admitted in diabetic ketoacidosis (DKA). The patient presents with dry, cracked lips and is begging for something to drink. Which reply would be the nurse's best response? a. "We can't give you anything to drink until we get your blood sugar under control." b. "You can have one cup of coffee without sugar." c. "You drink anything you want as long as its sugar free." d. "You can drink as much water has you can handle."

ANS: A Patients with DKA are kept on NPO status (nothing by mouth) until the hyperglycemia is under control.

The nurse is caring for a patient with a head injury who has developed diabetes insipidus (DI). What medication would the nurse expect to be prescribed for the patient? a. Vasopressin b. Insulin c. Glucagon d. Propylthiouracil

ANS: A Patients with central DI who are unable to synthesize antidiuretic hormone (ADH) require replacement ADH (vasopressin) or an ADH analog. The most commonly prescribed drug is the synthetic analog of ADH, desmopressin (DDAVP). DDAVP can be given intravenously, subcutaneously, or as a nasal spray. A typical DDAVP dose is 1 to 2 mcg intravenously or subcutaneously every 12 hours.

The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? a. Zone of coagulation b. Peripheral zone c. Zone of stasis d. Zone of hyperemia

ANS: A The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the least. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.

A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason? a. Presence of infection b. Lack of blood supply c. Lack of lymphatic drainage d. Contamination of the graft

ANS: B After the pigskin is in place, it may be dressed with antibacterial-impregnated dressings or other forms of dressings. Pigskin usually is removed or dissolves because of a lack of blood supply in 5 to 7 days. The pigskin is packaged in a variety of ways and in various sizes. It can be treated with silver sulfadiazine and can be meshed or nonmeshed. Pigskin can be used for temporary coverage of full- and partial-thickness wounds, burn wounds, and donor sites.

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan? a. Diabetes management b. Alcohol cessation c. Occult blood testing d. Anticoagulation management

ANS: B As the patient moves toward discharge, teaching should focus on the interventions necessary for preventing the recurrence of the precipitating disorder. If an alcohol abuser, the patient should be encouraged to stop drinking and be referred to an alcohol cessation program

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the practitioner to order for this patient? a. Histamine2 (H2) antagonists b. Vasopressin c. Heparin d. Antacids

ANS: B In acute variceal hemorrhage, control of bleeding can be accomplished through the use of pharmacologic agents. Intravenous vasopressin, somatostatin, and octreotide have been shown to reduce portal venous pressure and slow variceal hemorrhaging by constricting the splanchnic arteriolar bed

Which pathophysiologic mechanism occurs in the syndrome of inappropriate antidiuretic hormone (SIADH)? a. Hemoconcentration b. Dilutional hyponatremia c. Massive diuresis d. Hypermetabolism

ANS: B Patients with SIADH have an excess of antidiuretic hormone secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia

Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial- and full-thickness burns to half of his left arm, his entire left leg, and his perineum. a. 28% b. 23.5% c. 45.5%

ANS: B The arm represents 4.5%, the leg 18%, and the perineum 1%, totaling 23.5%.

The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence? a. Crackles in the lung bases b. Subcutaneous emphysema c. Incisional bleeding d. Absent of bowel sounds

ANS: B The clinical signs and symptoms include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck.

A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply.) a. Administer benzodiazepines for agitation. b. Monitor oxygen saturation. c. Initiate an insulin drip for hyperglycemia. d. Monitor serum electrolyte levels. e. Assess for signs of cerebral edema.

ANS: B, D, E The patient may experience a variety of other complications, including cerebral edema, cardiac dysrhythmias, acute respiratory failure, sepsis, and acute kidney injury. Cerebral edema and increased intracranial pressure develop as a result of breakdown of the blood-brain barrier and astrocyte swelling. Circulatory failure that mimics sepsis is common in acute liver failure and may exacerbate low cerebral perfusion pressure. Hypoxemia, acidosis, electrolyte imbalances, and cerebral edema can precipitate the development of cardiac dysrhythmias. Acute respiratory failure, progressing to acute respiratory distress syndrome, intrapulmonary shunting, ventilation-perfusion mismatch, sepsis, and aspiration may be attributed to the universal arterial hypoxemia.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. The nurse would monitor the patient for which side effect of the medication? a. Constipation b. Diarrhea c. Chest pain d. Bleeding

ANS: C A major side effect of the medication is systemic vasoconstriction, which can result in cardiac ischemia, chest pain, hypertension, acute heart failure, dysrhythmias, phlebitis, bowel ischemia, and cerebrovascular accident. These side effects can be offset with concurrent administration of nitroglycerin. Other complications include bradycardia and fluid retention

A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen? a. Allows for administration of tube feeding. b. Allows for testing of gastric secretions. c. Prevents tube from adhering to the gastric wall. d. Prevents the tube from advancing.

ANS: C The Salem sump has one lumen that is used for suction and drainage and another that allows air to enter the patient's stomach and prevents the tube from adhering to the gastric wall and damaging the mucosa.

A patient has been admitted after surgery for removal of a brain tumor. The nurse suspects the patient may be developing diabetes insipidus (DI). Which findings would confirm the nurse's suspicion? a. Hyperglycemia and hyperosmolarity b. Hyperglycemia and peripheral edema c. Intense thirst and passage of excessively large quantities of dilute urine d. Peripheral edema and pulmonary crackles

ANS: C The clinical diagnosis is made by the dramatic increase in dilute urine output in the absence of diuretics, a fluid challenge, or hyperglycemia. Characteristics of DI are intense thirst and the passage of excessively large quantities of very dilute urine

A patient with a history of type 2 diabetes was admitted after aneurysm repair. The patient's serum glucose levels have been elevated for the past 2 days and the patient is concerned about becoming dependent on insulin. Which statement is the nurse's best response to the patient's concerns? a. "This surgery may have damaged your pancreas. We will have to do more evaluation." b. "Perhaps your diabetes was more serious from the beginning." c. "You will need to discuss this with your physician." d. "The stress on your body has temporarily increased your blood sugar levels."

ANS: D Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and increasing hepatic gluconeogenesis.

Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? a. Uncontrolled pain b. Hypovolemia c. Worsening hypoxemia d. Decreased pulmonary compliance

ANS: D Circumferential full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Decreased pulmonary compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable what cause? a. Blood loss associated with burns and pain. b. Hemodynamic stability related to adequate fluid resuscitation. c. Over-resuscitation related to overestimation of the burn area involved. d. Under-resuscitation because of probable wound conversion.

ANS: D The rate of fluid administration is adjusted according to the individual's response, which is determined by monitoring urine output, heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient's intake and output is imperative to ensure that he or she is appropriately resuscitated. Under-resuscitation may result in inadequate cardiac output, leading to inadequate organ perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury. Over-resuscitation may lead to moderate to severe pulmonary edema; to excessive wound edema causing a decrease in perfusion of unburned tissue in the distal portions of the extremities; or to edema inhibiting perfusion of the zone of stasis, resulting in wound conversion.

A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% oxygen via a nonrebreathing mask.

ANS: D The treatment of choice for CO poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation. The half-life of CO in the body is 4 hours at room air (21% oxygen), 2 hours at 40% oxygen, and 40 to 60 minutes at 100% oxygen. The half-life of CO is 30 minutes in a hyperbaric oxygen chamber at three times the atmospheric pressure. Currently, the use of hyperbaric oxygen is of controversial benefit in the care of burn patients.

Using the Parkland formula for fluid resuscitation and knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL

B In a 75-kg person with a 37% burn injury (based on a "rule of nines" calculation: 18%—chest, 1%—perineum, 18%—right leg = 37% total body surface area (TBSA) burn), the Parkland formula estimates fluid resuscitation needs at 4 mL 37 75 = 11,100 mL. In the first 8 hours after injury, half of the calculated amount of fluid is administered. This amount equals 5550 mL.

Which topical antimicrobial agent is commonly used as a broad-spectrum agent and is activated by the wound moisture? a. Silver b. Bacitracin c. Mafenide acetate cream d. Silver sulfadiazine

A Silver has long been used for the treatment of wounds because of its broad-spectrum bacteriostatic properties against gram-negative and gram-positive bacteria. Silver has minimal side effects and minimal bacterial resistance. The other agents are applied topically and are not activated by wound moisture

The neuroendocrine stress response produces which findings? (Select all that apply.) a. Elevated blood pressure b. Decreased gastric motility c. Tachycardia d. Heightened pain awareness e. Increased glucose

ABCE The fight-or-flight response, or sympathetic nervous response, releases catecholamine that causes an increased heart rate and blood pressure. Blood is shunted form nonessential organs such as the stomach, glucose is made available to the brain cells, and pain awareness is decreased.

The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which medical intervention would the nurse expect to be ordered for this patient? a. Extensive hydration b. Oral hypoglycemic agents c. Large doses of IV insulin d. Limiting food and fluids

ANS: A Rapid IV fluid replacement requires the use of a volumetric pump. Insulin is administered intravenously to patients who are severely dehydrated or have poor peripheral perfusion to ensure effective absorption. Patients with DKA are kept on NPO (nothing by mouth) status until the hyperglycemia is under control. Critical care nurses are responsible for monitoring the rate of plasma glucose decline in response to insulin.

A patient is admitted after surgery with a history of hyperthyroidism. The nurse suspects the patient may be developing thyroid storm. Which finding would confirm this suspicion? a. Tachycardia b. Hypotension c. Decreased appetite d. Hypothermia

ANS: A Thyroid storm, also called thyroid crisis, is a rare and life-threatening exacerbation of hyperthyroidism. The pathophysiology underlying the transition from hyperthyroidism to thyroid storm is not fully understood because thyroid hormone levels are not necessarily different from patients with hyperthyroidism. Atrial fibrillation is the most common dysrhythmia in patients with hyperthyroidism, and tachydysrhythmias should be anticipated in thyroid storm, especially in patients with underlying heart disease.

A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? a. Superficial (first-degree) burn b. Partial-thickness (second-degree) burn c. Deep dermal partial-thickness (second-degree) burn d. Full-thickness (third-degree) burn

ANS: B A light to bright red or mottled appearance characterizes partial-thickness second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid, in turn, lifts off the thin damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth will heal in 7 to 21 days.

A patient has been admitted with diabetic ketoacidosis. The nurse knows that the top priority in the initial treatment of diabetic ketoacidosis (DKA) which intervention? a. Lowering the blood sugar as quickly as possible b. Administering intravenous fluids c. Administering sodium bicarbonate d. Determining the preci

ANS: B A patient with DKA is dehydrated and may have lost 5% to 10% of body weight in fluids. A fluid deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse

The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which symptom is most suggestive of DKA? a. Irritability b. Excessive thirst c. Rapid weight gain d. Peripheral edema

ANS: B DKA has a predictable clinical presentation. It is usually preceded by patient complaints of malaise, headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Nausea, vomiting, extreme fatigue, dehydration, and weight loss follow. Central nervous system depression, with changes in the level of consciousness, can lead quickly to coma.

A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage? a. Stress ulcers b. Peptic ulcers c. Nonspecific erosive gastritis d. Esophageal varices

ANS: B Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of the gastromucosal lining, is the leading cause of upper GI hemorrhage, accounting for approximately 21% of cases.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan? a. Continue as planned; everything looks good. b. IV rate should be decreased and colloids started. c. IV rate should be increased and fluid status closely watched. d. Fluids should be switched to packed red blood cells.

ANS: C Desired clinical responses to fluid resuscitation include a urinary output of 0.5 to 1 mL/kg/hr; a pulse rate lower than 120 beats/min; blood pressure in normal to high ranges; a central venous pressure less than 12 cm H2O or a pulmonary artery occlusion pressure less than 18 mm Hg; clear lung sounds; clear sensorium; and the absence of intestinal events, such as nausea and paralytic ileus

A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs as a result of what pathophysiologic mechanism? a. Uncontrolled hypoglycemia caused by an increased release of insulin b. Loss of storage capacity for senescent red blood cells c. Premature activation of inactive digestive enzymes, resulting in autodigestion d. Release of glycogen into the serum, resulting in hyperglycemia

ANS: C In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the central pathophysiologic mechanism of acute pancreatitis, namely autodigestion.

The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient? a. Insulin b. Vitamin K c. Lactulose d. Lorazepam

ANS: C Lactulose, a synthetic Ketoanalogue of lactose split into lactic acid and acetic acid in the intestine, is given orally through a nasogastric tube or as a retention enema. The result is the creation of an acidic environment that results in ammonia being drawn out of the portal circulation. Lactulose has a laxative effect that promotes expulsion. Vitamin K is used to help control bleeding. Insulin would be given to control hyperglycemia. Use of benzodiazepines and other sedatives is discouraged in a patient with ALF because pertinent neurologic changes may be masked, and hepatic encephalopathy may be exacerbated.

The nursing management plan for a patient with thyrotoxicosis would include which intervention? a. Providing diversional stimuli b. Restricting fluids c. Maintaining a quiet, restful environment d. Administering thyroid supplements at the same time each day

ANS: C Patients in thyroid storm are agitated, anxious, and unable to rest, and they benefit from an environment that is calm. Gradually, the effects of the antithyroid medications, iodides, and beta-adrenergic blocking drugs will decrease the neurologic symptoms related to the catecholamine sensitivity. Frequent reassurance and clear, simple explanations of the patient's condition help decrease the fear brought on by the onset thyroid storm.

A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the lack of insulin results in which process? a. Decreased glucagon release b. Decreased glycogenolysis c. Decreased ketone production d. Increased gluconeogenesis

ANS: D The release of glucagon from the liver is stimulated when insulin is ineffective in providing the cells with glucose for energy. Glucagon increases the amount of glucose in the bloodstream by breaking down stored glucose (glycogenolysis). In insulin deficiency states, fat is rapidly converted into glucose (gluconeogenesis). Ketoacidosis occurs when free fatty acids are metabolized into ketones: acetoacetate, beta-hydroxybutyrate, and acetone are the three ketone bodies that are produced.

A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury? a. Rhabdomyolysis b. Stress ulcers c. Pneumothorax d. Venous thromboembolism

A The electrical burn process can result in a profound alteration in acid-base balance and rhabdomyolysis, resulting in myoglobinuria, which poses a serious threat to renal function. Myoglobin is a normal constituent of muscle. With extensive muscle destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to intrinsic renal failure.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism? a. Portal hypertension b. Superficial mucosal erosions c. Breakdown the mucosal resistance d. Inflammation and ulceration

ANS: A Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop as a result of portal hypertension secondary to hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids. Without adequate sinusoid function, resistance to portal blood flow is increased, and pressures within the liver are elevated. This leads to a rise in portal venous pressure (portal hypertension), causing collateral circulation to divert portal blood from areas of high pressure within the liver to adjacent areas of low pressure outside the liver, such as into the veins of the esophagus, spleen, intestines, and stomach.

A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? a. Intravenous opiates and assessment of pulses in both arms b. Oral anti-inflammatory drugs and preparation for insertion of an arterial line c. Measurement of sedimentation rate and systemic antibiotics d. Application of splints and initiation of total parenteral nutrition

ANS: A Pain management in burn injuries must be addressed early and frequently reassessed t determine the adequacy of interventions. Intravenous opiates, such as morphine sulfate, are indicated and titrated to effect. Edema formation may cause neurovascular compromise to the extremities; assessments are necessary to evaluate pulses, skin color, capillary refill, and sensation.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement? a. 5950 mL of Lactated Ringer solution (LR) for the first 8 hours; then 5950 mL of LR over the next 16 hours b. 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic NS over the next 16 hours c. 11,900 mL of dextran evenly divided over the first 24 hours d. 11,475 mL of LR evenly divided over the first 24 hours

ANS: A Per the Parkland formula, you would administer 5950 mL of LR for the first 8 hours and 5950 mL of LR over the next 16 hours (4 mL 85 kg 45% = 15,300 mL in first 24 hours

Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? a. Daily assessment for proper fit and effectiveness b. Removal of splints during showers and dressing changes c. Allowing for frequent breaks from splint use d. Passive and active range of motion may be used instead of splints

ANS: A Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked daily for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times, except to assess the graft site for pressure points during every shift. Splints to correct severe contracture may be off for 2 hours per shift to allow burn care and range-of-motion exercises

The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which medical intervention would the nurse expect to see ordered for this patient? a. Rapid rehydration with intravenous fluids b. Insertion of a pulmonary artery catheter c. Administration of high-dose intravenous insulin d. Hourly monitoring of urine glucose and ketone levels

ANS: A The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of HHS must be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS.

The nursing management plan for a patient with full-thickness burns includes which intervention? a. Daily replacement of autografts b. Daily wound care with premedication c. Weekly wound care until all eschar is debrided d. Surgical skin grafting within 8 hours of admission

ANS: B Daily cleansing and inspection of the wound and unburned skin are performed to assess for signs of healing and local infection. Generally, this therapy is performed once or twice daily. Pain management and measures to reduce hypothermia are used. Patients should receive adequate premedication with analgesics and sedatives

A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What would be an appropriate response from the nurse? a. "This procedure is usually performed for cancer of the proximal esophagus and gastroesophageal junction." b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." c. "This procedure is usually performed for cancer of the pancreatic head." d. "The procedure is usually performed for varices of the distal esophagus and gastroesophageal junction."

ANS: B Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction.

patient has thyroid storm. The nurse is providing medication instruction for home. The patient asks "If I have a fever, should I take Tylenol or aspirin?" Which response would be the most appropriate? a. "Either one is fine because they do not affect the antithyroid medication." b. "Tylenol rather than aspirin because aspirin increases the amount of free thyroid hormone in circulation." c. "Aspirin rather than Tylenol because Tylenol increases the amount of free thyroid hormone in circulation." d. "They both prevent the antithyroid medication from working correctly. I would recommend an NSAID."

ANS: B For management or elevated temperature, patients are instructed to use acetaminophen rather than salicylates because salicylates increase the amount of free thyroid hormone in circulation.

The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention would have the highest priority? a. Preventing atelectasis b. Managing pain c. Promoting ambulation d. Preventing infection

ANS: B It is imperative to appropriately manage the patient's pain after GI surgery. Adequate analgesia is necessary to promote the mobility of the patient and decrease pulmonary complications. Initial pain management may be accomplished by intravenous opioid (morphine, hydromorphone) administration by means of a patient-controlled analgesia (PCA) pump, or through continuous epidural infusion of an opioid and local anesthetic (bupivacaine).

A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control? a. Administer analgesics only as needed. b. Administer analgesics around the clock. c. Educate the patient and family on lifestyle changes. d. Teach relaxation and distraction techniques.

ANS: B Pain management is a major priority in acute pancreatitis. Administration of around-the-clock analgesics to achieve pain relief is essential. Morphine, fentanyl, and hydromorphone are the commonly used narcotics for pain control. Relaxation techniques and the knee-chest position can also assist in pain control. However, the patient's pain needs to be addressed first.

Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage? a. Positioning the patient in a high-Fowler position b. Ensuring the patient has a patent airway c. Irrigating the nasogastric tube with iced saline d. Maintaining venous access so that fluids and blood can be administered

ANS: B Priorities in the medical management of a patient with gastrointestinal hemorrhage include airway protection, fluid resuscitation to achieve hemodynamic stability, correction of co-morbid conditions (e.g., coagulopathy), therapeutic procedures to control or stop bleeding, and diagnostic procedures to determine the exact cause of the bleeding.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? a. Clean the wounds and remove blisters. b. Assess the airway and provide 100% oxygen. c. Place a urinary drainage catheter and assess for myoglobin. d. Place a central intravenous access and provide antibiotics.

ANS: B The first priority of emergency burn care is to secure and protect the airway. All patients with major burns or suspected inhalation injury are initially administered 100% oxygen.

The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which findings would the nurse expect to observe in this patient? a. Hyperglycemia with low serum osmolality b. Severe hyperglycemia with minimal or absent ketosis c. Little or no ketosis in serum with rapidly escalating ketonuria d. Hyperglycemia and ketosis

ANS: B The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type II diabetes.

A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? (Select all that apply.) a. Calcium b. Serum amylase c. Serum glucose d. Potassium e. WBC f. Serum lipase

ANS: B, C, E, F Serum amylase, serum glucose, serum lipase, and WBCs are all elevated in acute pancreatitis while calcium and potassium decrease with acute pancreatitis.

According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that apply.) a. Arms b. Perineum c. Chest d. Genitalia e. Face

ANS: B, D, E According to triage criteria from the American College of Surgeons, burns on the face, hands, feet, genitalia, major joints, and perineum are best treated in a burn center.

A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record? a. Superficial partial-thickness burn b. Moderate partial-thickness burn c. Deep dermal partial-thickness burn d. Full-thickness burn

ANS: C Deep-dermal partial-thickness (second-degree) burns involve the entire epidermal layer and deeper layers of the dermis. A deep-dermal partial-thickness burn usually is not characterized by blister formation. Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure

A patient is admitted with diabetic ketoacidosis (DKA). The patient's arterial blood gas indicates the patient has an uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis? a. Initiate oxygen therapy via a face mask. b. Administer sodium bicarbonate. c. Administer insulin and fluids intravenously. d. Prepare for intubation.

ANS: C Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into glucose

The nurse is caring for a patient with acute liver failure. The practitioner asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom? a. Inflate a blood pressure cuff on the patient's arm. b. Have the patient bring the knees to the chest. c. Have the patient extend the arms and dorsiflex the wrists. d. Dorsiflex the patient's foot

ANS: C The patient should be evaluated for the presence of asterixis, or "liver flap," best described as the inability to voluntarily sustain a fixed position of the extremities. Asterixis is best recognized by downward flapping of the hands when the patient extends the arms and dorsiflexes the wrists

A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing which is characterized by rapid synthesis of collagen. What phase is the patient in? a. Wound phase b. Inflammatory phase c. Proliferative phase d. Maturation phase

ANS: C The proliferative phase of healing occurs approximately 4 to 20 days after injury. The key cell in this phase of healing, the fibroblast, rapidly synthesizes collagen. Collagen synthesis provides the needed strength for a healing wound. The inflammatory phase begins immediately after injury. Vascular changes and cellular activity characterize this period. Changes in the severed vessels occur in an attempt to wall off the wound from the external environment. The maturation phase, or remodeling phase, of healing occurs from approximately 20 days after injury to longer than 1 year after injury. During this period, the wound develops tensile strength as collagen deposits form scar tissue.

A patient is admitted with severe hyperglycemia. The patient is very lethargic and has a "fruity" odor to his breath. The nurse knows the odor on the patient's breath is indicative of which situation? a. Alcohol intoxication b. Lack of sodium bicarbonate c. Hypokalemia d. Presence of acetone

ANS: D Acid ketones dissociate and yield hydrogen ions (H+) that accumulate and precipitate a fall in serum pH. The level of serum bicarbonate also decreases consistent with a diagnosis of metabolic acidosis. Breathing becomes deep and rapid (Kussmaul respirations) to release carbonic acid in the form of carbon dioxide. Acetone is exhaled, giving the breath its characteristic "fruity" odor.

The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information? a. "Autografts are procured from both live and deceased donors." b. "Autografts can be placed at the bedside or in the operating room." c. "Autografts can transmit disease and be rejected." d. "Autografts provide permanent coverage and are the least expensive."

ANS: D An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient's burn wound to provide permanent coverage of the wound. Autografts must be done in the operating room and are the least expensive. Homografts can transmit disease and be rejected.

A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center? a. The size and depth of burn injury and the burning agent b. The age and present medical history of the patient c. The depth of the burn injury and the presence of soot in the sputum d. The medical history of the patient and the size and depth of the burn injury

ANS: D Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the above-mentioned factors, is of crucial importance in the overall plan of care and in decisions concerning patient management and appropriate referral to a burn center

A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery? a. Large doses of opioids given intramuscularly b. Intravenous opioids used in combination with oral antidepressants c. Large doses of opioids given subcutaneously d. Small doses of intravenous opioids titrated to effect

ANS: D Initially after burn injury, narcotics are administered intravenously in small doses and titrated to effect. The constant background pain may be addressed with the use of a patient-controlled analgesia device. When hemodynamic stability has occurred and gastrointestinal function has returned, oral narcotics can be useful. Intramuscular or subcutaneous injections must not be administered because absorption by these routes is unpredictable because of the fluid shifts that occur with burn injury

The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which statement best describes the rationale for administrating potassium supplements with the patient's insulin therapy? a. Potassium replaces losses incurred with diuresis. b. The patient has been in a long-term malnourished state. c. IV potassium renders the infused solution isotonic. d. Insulin drives the potassium back into the cells.

ANS: D Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is reversed. Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for patients with DKA who are receiving fluid resuscitation and insulin therapy.

A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery is a RYGBP. What would be an appropriate response from the nurse? a. "It is an esophagectomy performed using the transthoracic approach." b. "It is an esophagectomy performed using a transhiatal approach." c. "It is a combination of restrictive and malabsorption types of bariatric surgery. d. "It is a standard operation for pancreatic cancer."

C Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive, and (3) combined restrictive and malabsorptive. The Roux-en-Y gastric bypass combines both strategies by creating a small gastric pouch and anastomosing the jejunum to the pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased absorption of digestive materials. The standard operation for pancreatic cancer is a pancreaticoduodenectomy, also called the Whipple procedure.