Competency 12: Emergency and Disaster Preparedness

The nurse provides information to a laboratory employee who was accidentally exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement? A. "An antibiotic will be prescribed for 2 months." B. "I will need to wear a mask for the next 2 weeks." C. "Anthrax can be spread by person-to-person contact." D. "Antibiotics are only indicated for an active infection."

A. "An antibiotic will be prescribed for 2 months." Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Antibiotics are indicated after exposure to inhaled anthrax. A mask is not needed. Anthrax is not spread by person-to-person contact; anthrax is spread by direct contact with the bacteria and its spores.

The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas where it has been 100° F (37.7° C) or more for the last 2 weeks. With assessment, the nurse finds hypotension, body temperature of 104° F (40° C), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate? (Select all that apply.) A. Administer 100% O2. B. Immerse in an ice bath. C. Administer cool IV fluids. D. Cover the patient to prevent chilling. E. Administer acetaminophen (Tylenol).

A. Administer 100% O2. C. Administer cool IV fluids. The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient's ABC and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.

The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Administer 100% humidified oxygen. B. Teach the patient deep breathing exercises. C. Encourage the patient to express his feelings. D. Assist the patient to a high Fowler's position.

A. Administer 100% humidified oxygen. Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.

A 47-year-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6° F (30.3° C). Which action is most appropriate for the nurse to take? A. Administer warmed IV fluids. B. Position patient under a radiant heat lamp. C. Place an air-filled warming blanket on the patient. D. Immerse the extremities in a water bath (102° to 108° F [38.9° to 42.2° C]).

A. Administer warmed IV fluids. A patient with a core body temperature of 86.6° F (30.3° C) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4° F [43° C]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite.

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change? A. Morphine sulfate B. Sertraline (Zoloft) C. Zolpidem (Ambien) D. Enoxaparin (Lovenox)

A. Morphine sulfate Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant.

Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow? A. Patients should be routinely screened for family and IPV. B. Patients whom the nurse deems high risk should be assessed for IPV. C. All female patients and patients under 18 should be assessed for IPV. D. Patients should be assessed for IPV provided corroborating evidence exists.

A. Patients should be routinely screened for family and IPV. In the ED, the nurse needs to screen for family and IPV. Routine screening for this risk factor is required. Such assessment should not be limited to female, high-risk, or young patients, and evidence need not be present in order to screen for the problem

A patient has sought care 3 days after experiencing a series of tick bites. Which manifestation would indicate that a patient is experiencing tick paralysis? A. Respiratory distress B. Aggression and frequent falls C. Decreased level of consciousness D. Fever and necrosis at the bite sites

A. Respiratory distress A classic manifestation of tick paralysis is flaccid ascending paralysis, which develops over 1 to 2 days. Without tick removal, the patient dies as respiratory muscles become paralyzed. Aggression, decreased level of consciousness, fever, and necrosis at the bite sites are not characteristic of the problem.

The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation? (Select all that apply.) A. Urine output is 80 mL/hour. B. Heart rate is 86 beats/minute. C. Urine specific gravity is 1.025. D. Mean arterial pressure is 54 mm Hg. E. Systolic blood pressure is 88 mm Hg.

A. Urine output is 80 mL/hour. B. Heart rate is 86 beats/minute. Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be at least 0.5 to 1 mL/kg/hr. Cardiac factors include a mean arterial pressure (MAP) > 65 mm Hg, systolic blood pressure (BP) > 90 mm Hg, heart rate < 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030.

A community health nurse is determining available and needed supplies in the event of a bioterrorism attack. the nurse should be aware that community members exposed to anthrax will need access to which of the following medications? A. metronidazole B.Ciprofloxacin C.Zanamivir D.Fluconazole

A. metronidazole is used to treat trichomoniasis, skin infections, and septicemia. B.CORRECT: Community members exposed to anthrax will need access to ciprofloxacin. this medication is used for the prophylactic treatment of anthrax. C.Zanamivir is used to treat influenza. D.Fluconazole is used to treat candidiasis

A newly hired public health nurse is familiarizing himself with the levels of disaster management. Which of the following actions is a component of disaster prevention? A. outlining specific roles of community agencies B. identifying community vulnerabilities C.Prioritizing care of individuals D.Providing stress counseling

A. outlining specific roles of community agencies is a component of disaster preparedness. B.CORRECT:identifying community vulnerabilities is a component of disaster prevention. C.Prioritizing care of individuals is a component of disaster response. D.Providing stress counseling is a component of disaster recovery

A nurse on a sixth‑floor medical‑surgical unit is advised that a severe weather alert code has been activated. Which of the following actions should the nurse take? (select all that apply.) A. open window shades or drapes to provide better visibility of the external environment. B. Move beds of nonambulatory clients away from windows. C. relocate ambulatory clients into the hallways. D. Use the elevators to move clients to lower levels. E. turn the radio on for severe weather warnings.

A. the nurse should close the window shades and drapes to protect clients from shattering glass. B. CORRECT:the nurse should move the beds of nonambulatory clients away from windows to protect clients from shattering glass. C. CORRECT:the nurse should relocate ambulatory clients into the hallway to protect the clients from shattering glass. D. the nurse should instruct others that it is unsafe to use the elevator. E. CORRECT:the nurse should use the radio to monitor the activity of the storm.

A nurse is discussing disaster planning with the board members of a hospital. Which of the following individuals should the nurse expect to request extra supplies and staffing for the facility? A. incident commander B. Medical command physician C. triage officer D. Media liaison

A. the nurse should expect the incident commander to manage the incident and key leaders within the facility. B. CORRECT:the nurse should expect the medical command physician to oversee use of resources such as equipment and personnel. C. the nurse should expect the triage officer to prioritize the treatment of incoming clients D. the nurse should expect the media liaison to communicate with members of the media and press on behalf of the facility.

A community experiences an outbreak of meningitis, and hospital beds are urgently needed. Which of the following clients should the nurse recommend for discharge? A. a client newly admitted with angina and a history of myocardial infarction 1 year ago B. a client who has type 2 diabetes mellitus and was admitted for rotator cuff surgery C. a client admitted the day before with pneumonia and dehydration D. a client who has a fractured hip and is scheduled for total hip replacement the next day

A. the nurse should recognize that a client who has angina is at risk for a cardiac event. the nurse should not recommend this client for discharge because the client is unstable. B. CORRECT:the nurse should identify that this client is stable and his condition can be managed at home with surgery rescheduled. the nurse can safely recommend this client for discharge. C. the nurse should recognize a client who has dehydration and active infection requires ongoing nursing care. the nurse should not recommend this client for discharge because the client is unstable. D. the nurse should recognize that a client who has hip fracture is unstable, and at risk for further damage to her hip. the nurse should not recommend this client for discharge because the client is unstable.

A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A.Superficial thickness B.Superficial partial thickness C.Deep partial thickness D.Full thickness

A.CORRECT: A sunburn is a superficial thickness burn. Superficial burns damage the top layer of the skin. B.A superficial partial‑thickness burn results from flames or scalds. This damages the entire epidermis layer of the skin. C.A deep partial‑thickness burn can result from contact with hot grease. This affects the deep layers of the skin. D.A full‑thickness burn can result from contact with hot tar. This affects the dermis and sometimes the subcutaneous fat layer

A nurse is assessing a client who sustained deep partial‑thickness and full‑thickness burns over 40% of his body 24 hr ago. Which of the following are findings should the nurse expect? (Select all that apply.) A.Dyspnea B.Bradycardia C.Hyperkalemia D.Hyponatremia E.Decreased hematocrit

A.CORRECT: Dyspnea can occur during the initial phase following a burn due to airway injury and fluid shifts. B.Tachycardia occurs during the initial phase following a burn due to sympathetic nervous system compensation. C.CORRECT: Hyperkalemia occurs during the initial phase following a burn as a result of leakage of fluid from the intracellular space. D.CORRECT: Hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space. E.Hct increases during the initial phase of a burn due to hemoconcentration.

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A.Limit visitors in the client's room. B.Encourage fresh vegetables in the diet. C.Increase protein intake. D.Instruct the client to consume 2,000 calories/day. E.Restrict fresh flowers in the room.

A.CORRECT: The nurse should limit the number of visitors and limit the amount of time they can visit to decrease the risk of infection. B.The client should restrict consumption of fresh vegetables due to the presence of bacteria on the surface and the increased risk for infection. C.CORRECT: The client should increase protein consumption, which promotes wound healing and prevents tissue breakdown. D.The client should consume up to 5,000 calories/day because caloric needs double or triple beginning 4 to 12 days following the burn. E.CORRECT: Flowers should not be in the client's room due to the bacteria they carry, which increase the risk for infection.

A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the client's airway? A.Head‑tilt, chin‑lift B.Modified jaw thrust C.Hyperextension of the head D.Flexion of the head

A.CORRECT: The nurse should open the client's airway by the head‑tilt, chin‑lift because the client is unresponsive without suspicion of trauma. B.The nurse should not open the client's airway with the modified jaw thrust because this method is used for a client who is unresponsive with suspected traumatic neck injury. C.The nurse should not open the client's airway with hyperextension of the head because hyperextension of the head can close off the airway and cause injury. D.The nurse should not open the client's airway with flexion of the head because flexion of the head does not open the airway.

A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? (Select all that apply.) A.Remove wet clothing. B.Maintain normal room temperature. C.Apply warm blankets. D.Apply a heat lamp. E.Infuse warmed IV fluids.

A.CORRECT: This is an appropriate action by the nurse because the body temperature can rise more quickly when heat is applied to dry skin. B.The nurse should increase the temperature of the room to help return the client to a normal body temperature. C.CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when warm blankets are applied. D.CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when a heat lamp is safely applied. E.CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when warmed IV fluids are infused.

A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? A.Perform defibrillation. B.Prepare for transcutaneous pacing. C.Administer IV epinephrine. D.Elevate the client's lower extremities.

A.Defibrillation is not indicated for asystole, because this is not considered a shockable cardiac rhythm. B.Transcutaneous pacing is not indicated for the treatment of asystole. C.CORRECT: Administering epinephrine during asystole is an appropriate action by the nurse because it increases heart rate, improves cardiac output, and promotes bronchodilation. D.Elevating the client's lower extremities is indicated for the treatment of a client who is in shock, rather than asystole.

A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Of this total, 20% are full‑thickness burns on the arms, face, neck, and shoulders. The client's voice has become hoarse. He has a brassy cough and is drooling. The nurse should identify these findings as indications that the client has which of the following? A.Pulmonary edema B.Bacterial pneumonia C.Inhalation injury D.Carbon monoxide poisoning

A.Difficulty breathing and production of pink frothy sputum indicate pulmonary edema. B.Productive cough and a fever are indicative of a bacterial infection. C.CORRECT: Wheezing and hoarseness indicate inhalation injury with impending loss of the airway. These require immediate reporting to the provider. D.Confusion and headaches indicate carbon monoxide poisoning.

A community health nurse is educating the public on the agents of bioterrorism. Which of the following agents should the nurse include as Category A biological agents? (select all that apply.) A.Hantavirus B.Typhus C.Plague D. tularemia E. botulism

A.Hantavirus is a Category C biological agent. B. typhus is a Category b biological agent. C.CORRECT: Plague is a Category a biological agent. D.CORRECT:tularemia is a Category a biological agent. E.CORRECT:botulism is a Category a biological agent.

A nurse is preparing to administer fentanyl to a client who sustained deep partial‑thickness and full‑thickness burns over 60% of his body 24 hr ago. The nurse should plan to use which of the following routes to administer the medication? A.Subcutaneous B.Oral C.Intravenous D.Transdermal

A.The nurse should not give subcutaneous injections due to the difficulty of absorption from tissue during the resuscitation phase. B.The nurse should not give oral (including buccal, sublingual) medications due to decreased motility in the gastrointestinal tract during the resuscitation phase. C.CORRECT: The nurse should use the IV route to administer pain medication for rapid absorption and fast pain relief during the resuscitation phase. D.The nurse should not use the transdermal route of administration due to delays in absorption during the resuscitation phase

A nurse on a medical‑surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A.Client who has an ulceration of the right heel whose blood glucose is 300 mg/dL B.Client who reports right calf pain and shortness of breath C.Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D.Client who has dark red coloration of left toes and absent pedal pulse

A.The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client's condition. B.CORRECT: The nurse should identify that the client is at risk for respiratory arrest due to a possible embolism. The nurse should call the rapid response team because the manifestations can indicate the beginning of a rapid decline in the client's condition. C.This assessment does not indicate the beginning of a rapid decline in the client's condition at this time. The nurse should reassess the client and notify the provider if the bleeding increases. D.The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client's condition.

A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply.) A.Induce vomiting. B.Instill activated charcoal. C.Perform a gastric lavage with aspiration. D.Administer syrup of ipecac. E.Infuse IV fluids.

A.Vomiting places the client at risk for aspiration. B.CORRECT: This is an appropriate action by the nurse because activated charcoal adsorbs toxic substances, and the charcoal does not pass into the bloodstream. C.CORRECT: This is an appropriate action by the nurse because gastric lavage with aspiration removes the toxic substance when the instilled fluid is suctioned from the gastrointestinal tract. D.Administering syrup of ipecac is not recommended because it induces vomiting, which increases the client's risk for aspiration. E.CORRECT: This is an appropriate action by the nurse because intravenous fluids help dilute the toxic substances in the bloodstream and promote elimination from the body through the kidneys.

In reviewing the chart, which patient assessment is likely to have the greatest impact on this patient's risk of death from the accident? Tab 1-Background Male Found floating face down after surfing accident CPR done by rescuers Tab 2-ED assessment Sinus tachycardia with frequent premature ventricular contractions (PVCs) Mechanical ventilation Tab 3-Current assessment Left pupil size 10 cm, not reactive to light Pulmonary artery wedge pressure (PAWP)16 mm Hg PaO2 108 mm Hg, FIO2 50%, PEEP 5 cm Cool extremities, weak peripheral pulses A. PAWP 16 mm Hg B. Left pupil 10 cm, not reactive to light C. Sinus tachycardia with frequent PVCs D. Cool extremities, weak peripheral pulses

B. Left pupil 10 cm, not reactive to light Unilateral pupil dilation without response to light can be a clinical indicator of tentorial herniation of the brain and can occur in a surfing accident as the surfboard and patient are forcefully tossed around in the waves. If the excessive intracranial pressure is allowed to continue, the patient is at a high risk for brainstem death. This finding merits emergency interventions to prevent death. The PAWP, sinus tachycardia with frequent PVCs, and cool extremities with weak peripheral pulses do not indicate imminent death.

The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? A. Skin is hard with a dry, waxy white appearance. B. Skin is shiny and red with clear, fluid-filled blisters. C. Skin is red and blanches when slight pressure is applied. D. Skin is leathery with visible muscles, tendons, and bones.

B. Skin is shiny and red with clear, fluid-filled blisters. Deep partial thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.

4. Which patient should the nurse prepare to transfer to a regional burn center? A. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% B. A 39-year-old patient with a partial-thickness burn to the right upper arm C. A 53-year-old patient with a chemical burn to the anterior chest and neck D. A 42-year-old patient who is scheduled for skin grafting of a burn wound

C. A 53-year-old patient with a chemical burn to the anterior chest and neck The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.

An 18-year-old female has been admitted to the emergency department (ED) after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention? A. Induced vomiting B. Whole bowel irrigation C. Administration of activated charcoal D. Administration of fresh frozen plasma

C. Administration of activated charcoal Among the most common treatments for poisoning is the administration of activated charcoal. Induced vomiting is not typically indicated, and there is no need for plasma administration. Whole bowel irrigation may be used as an adjunct therapy later in treatment, but the use of activated charcoal is central to the treatment of poisonings.

A nurse teaches the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse describe that is expected of all licensed and unlicensed health care staff? A. Notify local, state, and national authorities. B. Assist security personnel to patrol the area. C. Learn the hospital emergency response plan. D. Contact the American Red Cross for assistance.

C. Learn the hospital emergency response plan All health care providers must be prepared for a mass casualty incident. The priority responsibility is to know the agency's emergency response plan.

A male patient is brought into the ED with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse's priority? A. Guard locked access doors. B. Maintain patient safety from revenge. C. Maintain personal and work place safety. D. Attain open patient airway and breathing.

C. Maintain personal and work place safety. The nurse's priority is to maintain personal and work place safety. Violence can erupt in the ED when treating gang members if the rival gang seeks revenge, or the patient's gang members seek to protect the patient with their presence. Staff members can be victims of that violence, so they should maintain a safe work environment by seeking law enforcement and security assistance in maintaining safety for the staff and the patient. ABCs are the usual priority, but this situation does not show any problem with the patient's airway or breathing.

There has been a mass casualty incident. Which patient would likely be designated "red" during triage at the site of this occurrence? A. An individual who is distraught at the violence of the incident B. An individual who has experienced an open arm fracture from falling debris C. An individual who is not expected to survive a crushing head and neck wound D. An individual whose femoral artery has been severed and is bleeding profusely

D. An individual whose femoral artery has been severed and is bleeding profusely Red indicates a life-threatening injury requiring immediate intervention, such as severe bleeding. Emotional trauma would not warrant a "red" designation, whereas a fracture would likely be deemed "yellow," urgent, but not life-threatening. Those not expected to survive are categorized "blue."

A mailroom worker was exposed to anthrax (Bacillus anthracis). He is not sure if he inhaled any of it or if it got on his skin because he dropped the envelope when he saw the powder. What treatment(s) should the nurse anticipate? A. Induce vomiting and administer antitoxin. B. Patient isolation to prevent spread of virus. C. Immediate vaccinia immune globulin (VIG). D. Ciprofloxacin (Cipro) to prevent systemic manifestations.

D. Ciprofloxacin (Cipro) to prevent systemic manifestations. To treat someone exposed to anthrax, antibiotics are effective to prevent systemic manifestations if treatment is begun early. Ciprofloxacin is the treatment of choice. Botulism is treated by inducing vomiting and administering antitoxin. A patient with hemorrhagic fever will be isolated to prevent the spread of the virus. Vaccinia immune globulin (VIG) is used for smallpox.

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care? (select all that apply) a. Escharotomy b. Administration of diuretics c. IV and oral pain medications d. Daily cleansing and debridement e. Application of topical antimicrobial agent

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

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)? a. Singed nasal hair b. Generalized pallor c. Painful swallowing d. Burns on the upper extremities e. History of being involved in a large fire

a. Singed nasal hair b. Generalized pallor c. Painful swallowing e. History of being involved in a large fire Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.

Pain management for the burn patient is most effective when (select all that apply) a.a pain rating tool is used to monitor the patient's level of pain. b.painful dressing changes are delayed until the patient's pain is completely relieved. c.the patient is informed about and has some control over the management of the pain. d.a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e.nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

a.a pain rating tool is used to monitor the patient's level of pain. c.the patient is informed about and has some control over the management of the pain. d.a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). Rationale: The use of a pain rating tool assists the nurse in the assessment, monitoring, and evaluation of the pain management plan. The more control the patient has in managing the pain, the more successful the chosen strategies are. A selected variety of medications offer better pain relief for patients with burns, whose pain can be both continuous and treatment related over varying periods of time. It is not realistic to promise a patient that pain will be completely eliminated. It is not realistic to suggest that pain will be managed (during any phase of burn care) with nonpharmacologic pain management. Such management is meant to be adjuvant and individualized.

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a.applying pressure garments. b.repositioning the patient every 2 hours. c.performing active ROM at least every 4 hours. d.massaging the new tissue with water-based moisturizers.

a.applying pressure garments. Rationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a.blisters. b.exposed fascia. c.exposed muscles. d.intact nerve endings. e.red, shiny, wet appearance.

a.blisters. d.intact nerve endings. e.red, shiny, wet appearance. Rationale: The appearance of partial-thickness (deep) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.

When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? (select all that apply)? a. The exercises are the only way to prevent contractures. b. Active and passive ROM maintain function of body parts. c. ROM will show the patient that movement is still possible. d. Movement facilitates mobilization of leaked exudates back into the vascular bed. e. Active and passive ROM can only be done while the dressings are being changed.

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

The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? a. SQ tetanus toxoid b. IV morphine sulfate c. IM hydromorphone (Dilaudid) d. PO oxycodone and acetaminophen (Percocet)

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

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? a. Begin IV fluid replacement. b. Monitor for signs of complications. c. Assess and manage pain and anxiety. d. Discuss possible reconstructive surgery.

b. Monitor for signs of complications. Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? a. The total 24-hour fluid requirement should be administered in the first 8 hours. b. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. c. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. d. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

b. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? a. Blisters b. Reddening of the skin c. Destruction of all skin layers d. Damage to sebaceous glands

b. Reddening of the skin The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? a. GI distress b. Tachycardia c. Restlessness d. Hypokalemia

b. Tachycardia Albuterol (Ventolin) stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.

An older man arrives in triage disoriented and tachypneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to a.obtain a detailed medical history from his wife. b.assess his vital signs, including a rectal temperature. c.determine the kind of insurance he has before treating him. d.start supplemental oxygen and have the ED physician see him.

b.assess his vital signs, including a rectal temperature. Rationale: After the primary survey, the triage nurse should obtain a full set of vital sign measurements (including temperature). Core body temperature can be obtained rectally. Clinical manifestations of heatstroke include hot, dry skin; altered mental status (ranging from confusion to coma); hypotension; tachycardia; weakness, and a temperature higher than 104° F (40° C).

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in her new home? a. Cook for her. b. Stop her from smoking. c. Install tap water anti-scald devices. d. Be sure she uses an open space heater.

c. Install tap water anti-scald devices. Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.

The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient? a. Replace the blood lost. b. Maintain a neutral pH. c. Maintain fluid balance. d. Replace serum potassium.

c. Maintain fluid balance. This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? a. Sit or lay in the position of comfort. b. Wear a pressure garment for 8 hours each day. c. Refer the patient to a counselor for psychosocial support. d. Use the sun to increase the skin color on the healed areas.

c. Refer the patient to a counselor for psychosocial support. In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way they looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.

Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a.Set hot water temperature at 140° F (60° C). b.Use only hardwired smoke detectors. c.Encourage regular home fire exit drills. d.Never permit older adults to cook unattended.

c.Encourage regular home fire exit drills. Rationale: A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used. Supervision of older adults who are cooking is necessary only if cognitive alterations are observed.

An older woman arrives in the ED complaining of severe pain in her right shoulder. The nurse notes that her clothes are soiled with urine and feces. She tells the nurse that she lives with her son and that she "fell." She is tearful and asks you if she can be admitted. What possibility should the nurse consider? a.Paranoia b.Possible cancer c.Family violence d.Orthostatic hypotension

c.Family violence Rationale: Family and intimate partner violence is a pattern of coercive behavior in a relationship that involves fear, humiliation, intimidation, neglect, and intentional physical, emotional, financial, or sexual injury.

A patient is recovering from second- and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to a.arrange a return-to-clinic appointment and prescription for pain medications. b.teach the patient and the caregiver proper wound care to be performed at home. c.review the patient's current health care status and readiness for discharge to home. d.give the patient written discharge information and websites for additional information for burn survivors.

c.review the patient's current health care status and readiness for discharge to home. Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge.

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a.adherence of albumin to vascular walls. b.movement of potassium into the vascular space. c.sequestering of sodium and water in interstitial fluid. d.hemolysis of red blood cells from large volumes of rapidly administered fluid.

c.sequestering of sodium and water in interstitial fluid. Rationale: During the emergency phase, sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases.

The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? a. Severe pain, blisters, and blanching with pressure b. Pain, minimal edema, and blanching with pressure c. Redness, evidence of inhalation injury, and charred skin d. No pain, waxy white skin, and no blanching with pressure

d. No pain, waxy white skin, and no blanching with pressure With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a.Obtain vital signs and a STAT arterial blood gas. b.Encourage the patient to cough and auscultate the lungs again. c.Document the findings and continue to monitor the patient's breathing. d.Anticipate the need for endotracheal intubation and notify the physician.

d.Anticipate the need for endotracheal intubation and notify the physician. Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

A chemical explosion occurs at a nearby industrial site. The first responders report that victims are being decontaminated at the scene and approximately 125 workers will need medical evaluation and care. The nurse receiving this report should know that this will first require activation of a.a code blue alert. b.a disaster medical assistance team. c.the local police and fire departments. d.the hospital's emergency response plan.

d.the hospital's emergency response plan. Rationale: The term emergency usually refers to any extraordinary event (e.g., multicasualty train crash) that necessitates a rapid and skilled response and that the community's existing resources can manage.

An 18-year-old male who fell through the ice on a pond near his farm was admitted to the ED with somnolence. Vital signs are BP 82 mm Hg systolic with Doppler, respirations 9/min, and core temperature of 90° F (32.2° C). The nurse should anticipate which intervention? A. Active core rewarming B. Immersion in a hot bath C. Rehydration and massage D. Passive external rewarming

A. Active core rewarming Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.

Which assessment parameter will the nurse address during the secondary survey of a patient in triage? A. Blood pressure and heart rate B. Patency of the patient's airway C. Neurologic status and level of consciousness D. Presence or absence of breath sound and quality of breathing

A. Blood pressure and heart rate Vital signs are considered to be a part of the secondary survey in the triage process. Airway, breathing, circulation, and a brief neurologic assessment are components of the primary survey that is done to identify life-threatening conditions.

A 71-year-old woman arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask? A. "Do you feel like you have a fever?" B. "What time did you take the medication?" C. "Have you tried to commit suicide before?" D. "Are you experiencing any abdominal pain?"

B. "What time did you take the medication?" Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons.

A nurse is performing triage in the emergency department. Which patient should the nurse see first? A. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg B. 32-year-old patient with drug overdose who is unresponsive with a poor respiratory effort C. 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath D. 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg

B. 32-year-old patient with drug overdose who is unresponsive with a poor respiratory effort The patient with a drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last.

Effective interventions to decrease absorption or increase elimination of an ingested poison include which of the following (select all that apply)? a.Hemodialysis b.Milk dilution c.Eye irrigation d.Gastric lavage e.Activated charcoal

a.Hemodialysis d.Gastric lavage e.Activated charcoal Rationale: Options for decreasing absorption of ingested poisons include activated charcoal and gastric lavage. Administration of cathartics, whole-bowel irrigation, hemodialysis, urine alkalinization, chelating agents, and antidotes increases the elimination of poisons.

To maintain a positive nitrogen balance in a major burn, the patient must a.eat a high-protein, low-fat, high-carbohydrate diet. b.increase normal caloric intake by about three times. c.eat at least 1500 calories/day in small, frequent meals. d.eat rice and whole wheat for the chemical effect on nitrogen balance.

a.eat a high-protein, low-fat, high-carbohydrate diet. Rationale: The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing.

The injury that is least likely to result in a full-thickness burn is a.sunburn. b.scald injury. c.chemical burn. d.electrical injury.

a.sunburn. Rationale: Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current.

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? a. 18% b. 22.5% c. 27% d. 36%

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

A patient has a core temperature of 90° F (32.2° C). The most appropriate rewarming technique would be a.passive rewarming with warm blankets. b.active internal rewarming using warmed IV fluids. c.passive rewarming using air-filled warming blankets. d.active external rewarming by submersing in a warm bath.

b.active internal rewarming using warmed IV fluids. Rationale: Moderate hypothermia (temperature of 86° to 93.2° F) causes rigidity, bradycardia, slowed respiratory rate, blood pressure obtainable only by Doppler measurement, metabolic and respiratory acidosis, and hypovolemia. Techniques include heated (up to 111.2° F [44° C]), humidified oxygen; warmed IV fluids (up to 98.6° F [37° C]); peritoneal lavage with warmed (up to 113° F [45° C]) fluids; and extracorporeal circulation with cardiopulmonary bypass, rapid fluid infuser, or hemodialysis.

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a.reapply a new dressing without disturbing the wound bed. b.observe the wound for signs of infection during dressing changes. c.apply cool compresses for pain relief in between dressing changes. d.wash the wound aggressively with soap and water three times a day.

b.observe the wound for signs of infection during dressing changes. Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. Mannitol 75 gm IV b. Urine for myoglobulin c. Lactated Ringer's at 25 mL/hr d. Sodium bicarbonate 24 mEq every 4 hours

c. Lactated Ringer's at 25 mL/hr Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2-4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? a. Serum sodium and potassium increase b. Serum sodium and potassium decrease. c. Edema and arterial blood gases improve. d. Diuresis occurs and hematocrit decreases.

d. Diuresis occurs and hematocrit decreases. In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of RBCs and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? a. Full liquids only b. Whatever the patient requests c. High-protein and low-sodium foods d. High-calorie and high-protein foods

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