Exam #11
A critical care nurse knows to assess the cardiac system for the probable cause of heart disease subsequent to trauma. Which of the following is a major concern? A) Heart block B) Pericarditis C) Cardiac tamponade D) Mitral regurgitation
C) Cardiac tamponade Cardiac tamponade is a condition in which fluid accumulates in the pericardium. This can occur as the result of penetrating or blunt chest trauma
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? A) Administer an analgesic as ordered. B) Massage the extremities. C) Elevate the legs. D) Apply a heat lamp.
A) Administer an analgesic as ordered During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next A) Administers oxygen by nasal cannula at 2 liters per minute B) Re-assesses the vital signs C) Contacts the admitting physician D) Calls the Rapid Response Team
A) Administers oxygen by nasal cannula at 2 L/min The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.
A teenage boy has been brought by ambulance to the emergency department from a house fire in which he has suffered extensive injuries. In addition to burns, early blood tests reveal carbon monoxide poisoning. This assessment finding will be treated by what intervention? A) Administration of 100% oxygen B) Intubation and administration of bronchodilators C)Deep suctioning D) Incentive spirometry
A) Administration of 100 % oxygen
The nurse recognizes the first dressing change at the site of an autograft is performed A) as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery. B) within 12 hours after surgery. C) within 24 hours after surgery. D) as soon as sanguineous drainage is noted.
A) As soon as foul odor or purulent drainage is noted, or 2-5 days after surgery
A nurse is preparing an in-service education program to a group of nurses who are members of a disaster response team specializing in biologic weapons. Which of the following would the nurse include as the agent of choice when dealing with a mass casualty incident involving anthrax? A) Ciprofloxacin B) Penicillin C) Erythromycin D) Gentamicin
A) Ciprofloxacin
Which of the following observations helps the nurse in determining adequate oxygenation? A) Appearance of lunula B) Hard keratin C) Pink nail beds D) Capillary refill time
C) Pink nail beds The nurse observes the color of the nail beds. Pink nail beds suggest adequate oxygenation. Lunula does not signify adequate oxygenation. Fingernails and toenails are layers of hard keratin that have a protective function. Hence, hard keratin does not signify adequate oxygenation. Capillary refill time is an assessment for tissue perfusion.
A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: A) Constrict blood vessels in the cardiorespiratory system. B) Decrease heart rate. C) Relax the bronchioles. D) Vasodilate the skeletal muscles.
A) Constrict blood vessels in the cardiorespiraotry system Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.
Which antimicrobials is not commonly used to treat burns? A) tetracycline B) silver sulfadiazine (Silvadene) C) mafenide (Sulfamylon) D) silver nitrate (AgNO3) 0.5% solution
A) Tetracycline
The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in? A) Initial B) Compensatory C) Progressive D) Irreversible
C) Progressive In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline.
A patient has a moisture-retentive dressing for the treatment of a sacral decubitus ulcer. How long should the nurse leave the dressing in place before replacing it? A) 4 to 6 hours B) 8 hours C) 12 to 24 hours D) 24 to 36 hours
C) 12 to 24 hours Depending on the product used and the type of dermatologic conditions encountered, most moisture-retentive dressings may remain in place from 12 to 24 hours.
The nurse is actively managing the intravenous fluid administration for a patient who has developed cardiogenic shock after a myocardial infarction. When performing this aspect of nursing care, what principle should guide the nurse's decision making? A) Adequate fluid resuscitation must be balanced against the risk of fluid overload. B) Intravenous fluid should be infused as quickly as possible in emergency treatment. C) In order to prevent increased afterload, the patient should not receive more than 125 mL of total intravenous fluid in 60 minutes. D) Temporary fluid restriction reduces cardiac workload and improves cardiac output.
A) Adequate fluid resuscitation must be balanced against the risk of fluid overload. The nurse plays a critical role in the safe and accurate administration of intravenous fluids and medications. Fluid overload and pulmonary edema are risks because of ineffective cardiac function and accumulation of blood and fluid in the pulmonary tissues. At the same time, the patient requires intravenous fluids to maintain adequate intravascular volume. Fluid restriction, however, is not the means to achieving this balance.
A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames? A) 2 to 4 weeks B) 1 week C) 6 weeks D) 8 weeks
A) 2 to 4 weeks
When caring for patients with respiratory system failure, the critical care nurse understands that a major health disorder caused by hypoxemic respiratory failure is: A) Acute respiratory distress syndrome. B) Pulmonary edema. C) Chronic bronchitis. D) Emphysem
A) Acute respiratory distress syndrome There are four causes for hypoxemic respiratory failure: anemia, hemorrhage, intracardiac shunts, and acute respiratory distress syndrome (ARDS). The other choices are caused by ventilatory respiratory failure.
A nuclear accident (intentional or unintentional) can cause significant harm to those living nearby or at a distance. Harmful levels of invisible gamma radiation penetrate the body, not only causing devastating injuries but possibly contaminating others. What type of transmission precaution prevents such person-to-person contamination? A) contact B) airborne C) droplet D) standard
A) Contact Invisible gamma radiation penetrates the body and can be eliminated in blood, sweat, urine, and feces. Consequently, a contaminated person can contaminate others through contact with body fluids or surfaces he or she touches. Airborne transmission requires the suspension and transport on air currents beyond 3 feet and is the way in which many pathogens or toxins are transmitted. Invisible gamma rays do not fall into this category, however. Gamma radiation does not travel in a liquid, or droplet, form. Standard precautions encompass more than person-to-person contamination.
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? A) Diagnostic and laboratory testing B) Assessment of peripheral pulses C) Establishing a patent airway D) Undressing the client
A) Diagnostic and laboratory testing Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.
The nurse is assessing an acutely ill patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock when: A) Fluid circulating in the blood vessels decreases. B) Cardiac output is increased. C) Blood pressure increases. D) Pulse is fast and bounding.
A) Fluid circulating in the blood vessels decreases Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and the pulse is fast but weak.
A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock? A) HR, 48 bpm; BP, 90/60 mm Hg B) Cool, moist skin C) HR, 120 bpm; BP, 88/58 mm Hg D) Shortness of breath
A) HR, 48 bpm; BP, 90/60 mm Hg
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? A) Head injury B) Myocardial infarction C) Diabetes D) Multiple sclerosis
A) Head injury An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries.
Which of the following reflect the pathophysiology of cutaneous signs of HIV disease? A) Immune function deterioration B) High CD4 count C) Genetic predisposition D) Decrease in normal skin flora
A) Immune function deterioration
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? A) inflammatory B) neuroendocrine C) intravascular fluid excess D) hypertension
A) Inflammatory
The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following? A) Liquid blood component is lost into extravascular space B) Decreased renal blood flow C) Fluid loss D) Sodium and water retention caused by increase adrenocortical activity
A) Liquid blood component is lost into extravascular space Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity.
A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? A) Liver B) Stomach C) Large intestine D) Kidneys
A) Liver
Which medication reverses severe respiratory depression and coma? A) Naloxone hydrochloride B) Diazepam C)Flumazenil D) N-acetylcysteine
A) Naloxone hydrochloride Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma. Diazepam is a benzodiazepine. Flumazenilis a benzodiazepine antagonist. N-acetylcysteine is used for acetaminophen toxicity.
The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? A) Pulmonary edema B) Pneumonia C) Congestive heart failure D) Panic attack
A) Pulmonary edema
Morphine sulfate has which of the following effects on the body? A) Reduces preload B) Increases preload C) Increases afterload D) No effect on preload or afterload
A) Reduces preload In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).
The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? A) Septic B) Anaphylactic C) Neurogenic D) Cardiogenic
A) Septic In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.
A client has been exposed to and inhaled botulism. When providing care to this client, which of the following would be necessary for the nurse to follow? A) Standard precautions B) Droplet precautions C) Airborne precautions D) Contact precautions
A) Standard precautions Standard precautions are used when providing care to clients with botulism because the agent is not contagious through human-to-human contact. Other precautions such as droplet, airborne, or contact precautions are not necessary.
A nurse is conducting a comprehensive assessment of an elderly man who has been admitted to the geriatric medical unit with dehydration and suspected malnutrition. The nurse's examination of the patient's integumentary system reveals several notable findings. Which of the following findings most clearly warrants medical follow-up? A) The patient has an irregularly shaped mole on his scalp that has been growing in recent months B) There is dark discoloration of the skin on the patient's shins and ankles and the skin has a shiny appearance. C) There is a yellowish waxy deposit on the patient's upper and lower eyelids. D) The patient has numerous superficial red marks on the skin of his forearms and the backs of his hands.
A) The patient has an irregularly shaped mole on his scalp that has been growing in recent months. Changes in the size or character of a mole are suggestive of malignancy. Darkening of the skin (melasma), waxy deposits (xanthelasma) and superficial red marks (telangiectasias) are benign, age-related findings
The nurse is caring for a client who has been on a mechanical ventilator since admission to the intensive care unit 4 days ago. Upon assessment, the nurse notes the client has tachycardia, a temperature of 102.2°F (39°C) and purulent secretions upon suctioning. Chest auscultation reveals crackles in the right lower lung lobe. The nurse should suspect which respiratory complication? A) Ventilator associated pneumonia (VAP) B)Gastrointestinal bleed C) Pneumothorax D) Pulmonary embolism (PE)
A) VAP
The nurse is caring for a client with herpes zoster. The nurse documents the lesions as A) vesicles. B) wheals. C) pustules. D) cysts.
A) Vesicles The lesions form herpes zoster are vesicles, defined as circumscribed, elevated, palpable masses that contain serous fluid and are less than 0.5 cm in diameter. Wheals are elevated masses with transient, irregular borders. Pustules are pus-filled lesions. Cysts are encapsulated fluid-filled or semisolid masses in the subcutaneous tissue or dermis.
Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? A) Vitiligo B) Hirsutism C) Lichenification D) Telangiectases
A) Vitiligo Vitiligo results in the development of white patches that may be localized or widespread. Hirsutism is the condition of excessive hair growth. Lichenification refers to a leathery thickening of the skin. Telangiectases refers to red marks on the skin caused by stretching of the superficial blood vessels
The nurse's hourly assessment of a male patient with burns reveals that the patient's blood pressure is trending downward and that his heart rate is trending upward. What intervention has the potential to resolve these trends? A) Increasing the rate of the patient's fluid resuscitation B) Performing intermittent urinary catheterization C)Increasing the rate of the patient's morphine infusion D) Repositioning the patient
A) increasing the rate of the patient's fluid resuscitation Low blood pressure and increased heart rate may indicate hypovolemic shock, a problem that may be addressed by measures that include increasing the rate of the patient's fluid resuscitation.
A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of A) pulmonary edema. B) hypothermia. C) hyponatremia. D) head injury.
A) pulmonary edema Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia. Hypothermia and head injury may be associated with near drowning but would be apparent at the time of admission and would not develop after several hours.
The nurse is instructing the parents of a child with head lice. Which statement should the nurse include? A) Use shampoo with piperonyl butoxide. B) Use shampoo with Kwell. C) Wash clothes in cold water. D) Disinfect brushes and combs with bleach.
A) use shampoo with piperonly butoxide The nurse's instructions should include shampooing with piperonyl butoxide, washing clothes in hot water, and disinfecting brushes and combs with piperonyl butoxide shampoo.
A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? A) "I should always wear something on my feet when I'm outside." B) "Brightly colored clothes help to ward off bees." C)"If a bee comes near me, I should stay still." D)"I need to avoid using perfumes and scented soaps when I'm going outside."
B) Brightly colored clothes help to ward off bees
The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock? A) Hypervolemic B) Distributive C) Restrictive D) Cardiotonic
B) Distributive The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. This makes options A, C, and D incorrect.
Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? A) Prevent infection B) Fluid resuscitation C) Endotracheal tube placement D) Strict intake and output
B) Fluid restriction Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? A) Anemia B) Gastric ulcers C) Hyperthyroidism D) Cardiac arrest
B) Gastric ulcers The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.
You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? A) Shock begins in the decompensation stage. B) In the compensation stage, catecholamines are released. C) Antiduretic and corticosteroid hormones are released at the beginning of the irreversible stage. D) The renin-angiotensin-aldosterone system fails in the compensation stage.
B) In the compensation stage, catecholamines are released Compensatory mechanisms include the release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. Shock does not begin in the decompensation stage.
The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? A) Decreased white blood cell count B) Increase in arterial oxygenation C) Decreased depressive symptoms D) Regulation of sodium and potassium
B) Increase in arterial oxygenation Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.
Which drug is an oral retinoid used to treat acne? A) Estrogen B) Isotretinoin C) Tetracycline D) Benzoyl peroxide
B) Isotretinoin
A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock following insertion of an intravenous catheter. The nurse first A) Maintains the head of the bed at 30 degrees B) Lays the client flat with the feet elevated C) Administers a bolus of intravenous (IV) fluids D) Assesses the client's blood glucose level
B) Lays the client flat with the feet elevated The client may have fainted, which is a sign of transient neurogenic shock. To minimize pooling of blood in the legs and to restore blood flow to the brain, the nurse lays the client flat and elevates his or her feet. Another cause may be hypoglycemia. If the above action does not resolve the client's problem, the nurse should assess the client's blood glucose level. Raising the head of the bed would be done if the client had received spinal or epidural anesthesia. A bolus of IV fluids would be given if the client were dehydrated.
When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure? A) Respiratory alkalosis B) Myocardial depression C) Rapid, shallow respirations D) Lethargy and confusion
B) Myocardial depression The body's inability to meet increased oxygen requirements produces ischemia, and biochemical mediators cause myocardial depression. This leads to failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin.
Which vasodilator medication is used in the treatment of shock? A) Dopamine B) Nitroglycerin C) Norepinephrine D) Dobutamine
B) Nitroglycerin
A nurse volunteers to help decontaminate a victim. Which is the first action that the nurse should take? A) Washing victim with soap and water, then rinsing B)Removing the victim's clothing and jewelry C) Dressing the victim in personal protective equipment D) Applying chemical decontamination foam to the area
B) Removing the victim's clothing and jewelry
An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned that he has melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of? A) Senile keratoses B) Senile lentigines C) Melanoma D) Freckles
B) Senile lentigines Small, brown, pigmented, benign lesions, known as liver spots or senile lentigines, form on the hands and forearms of older people. Small, yellow or brown, raised lesions called senile keratoses may appear on the face and trunk and are precancerous and require close observation. Melanoma is diagnosed by biopsy and generally has irregular borders and is dark in color.
A client has been exposed to a vesicant and is undergoing decontamination. Which of the following most likely would be used? A) Sodium hypochlorite B) Soap and water C) Alcohol D) Chlorhexidine
B) Soap and water A client who is exposed to a vesicant agent undergoes decontamination with soap and water. Scrubbing with sodium hypochlorite solutions is avoided because they increase penetration of the nerve agent. Alcohol and chlorhexidine are inappropriate choices for decontamination.
When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? A) Brachial artery B) Radial artery C) Aorta D)Right ventricular wall
C) Aorta Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall
A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp? A) Temporal area B) Top of the head C) Behind the ears D) Middle area
C) Behind the ears
An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? A) The client is in hypovolemic shock. B) The client has experienced extensive full-thickness burns. C) The paramedic administered high doses of opioids during transport. D) The client has experienced partial-thickness burns.
B) The client has experienced extensive full-thickness burns In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? A) The client's heart rate is rapid. B) The client's urinary output is 0.5 mL/kg/hour. C) The client's breathing is unlabored and skin is clammy. D) The client is conscious.
B) The client's urinary output is 0.5 mL/kg/hr Successful fluid resuscitation is gauged by a urinary output of 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.
The nurse is triaging victims after an explosion at an oil refinery. One victim reports tinnitus, dizziness, and otorrhea. For what probable condition should the nurse prepare care? A) Blast lung B) Tympanic rupture C) Head injury D) Abdominal injury
B) Tympanic rupture The nurse should prepare to care for a client with probable tympanic rupture. Signs and symptoms of tympanic rupture include hearing loss, tinnitus, pain, dizziness, and otorrhea. Symptoms of blast lung include dyspnea, hypoxia, tachypnea or apnea, cough, chest pain, and hemodynamic instability. Symptoms of head injury include postconcussive syndrome. Symptoms of abdominal injury include pain, guarding, rebound tenderness, rectal bleeding, nausea, and vomiting.
Which term refers to the tendency for a chemical to become a vapor? A) Persistence B) Volatility C) Toxicity D) Latency
B) Volatility The most common volatile agents are phosgene and cyanide. Persistence means that the chemical is less likely to vaporize and disperse. Toxicity is the potential of an agent to cause injury to the body. Latency is the time from absorption to the appearance of symptoms.
The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? A) Central venous pressure of 6 mm Hg B) Mean arterial pressure of 70 mm Hg C) Urine output of 0.2 mL/kg/hr D) ScvO2 of 60%
B) mean arterial pressure of 70 mm Hg The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.
The nurse is documenting an hourly assessment of a patient who is being treated for full-thickness burns to his lower extremities. Assessment has revealed that the patient's abdominal girth is steadily increasing. This is most likely attributable to what pathophysiological process? A) Presence of free air under the patient's diaphragm B) Third spacing C) Bladder distention due to urinary retention D) Paralytic ileus
B) third spacing Fluid shifts into the abdominal cavity causing increased abdominal distention that interferes with pulmonary ventilation. An increase in abdominal girth would be suggestive of third spacing into the peritoneal space. Bladder distention, paralytic ileus, and free air are less likely to cause an increase in abdominal girth.
The nurse is orienting to the emergency department and finds cases of potassium iodine tablets located in the supply closet. The nurse asked the nurse manager why this is stored in the closet. The nurse manager's best response is: A)"Potassium iodine is given to individuals who come to the emergency department dehydrated to replenish their potassium level." B) "Potassium iodine is given to individuals diagnosed with hypothyroidism in the emergency department." 4 C) "Potassium iodine is given to individuals as a prophylaxis for protecting the thyroid gland from absorption of radiation in case of an accident at the local nuclear plant." D) "Potassium iodine is given to individuals who are given furosemide intravenously in the emergency department to replenish their potassium level."
C) "Potassium iodine is given to individuals as a prophylaxis for protecting the thyroid gland from absorption of radiation in case of an accident at the local nuclear plant."
What quick assessment technique should the nurse use to assess the percentage of burn injury? A) Observe the color of the client's wound B) Check the client's vital signs C) Compare the client's palm with the size of the burn wound D) Observe the client's level of consciousness
C) Compare the client's palm with the size of the burn wound A quick technique to assess the percentage of burn injury is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's total body surface area. Observing the color of the client's wound, checking the client's vital signs, and observing the client's level of consciousness determine the client's health status but do not help assess the percentage of burn injury.
A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding? A) Bradycardia B) Rising blood pressure C) Delayed capillary refill D) Pale pink dry skin
C) Delayed capillary refill If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? A) Anaphylaxis B) Sepsis C) Hypovolemia D) Cardiac dysfunction
C) Hypovolemia Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.
The nurse is conducting a community education program on basal cell carcinoma (BCC). Which statement should the nurse make? A) It is more invasive than squamous cell carcinoma (SCC). B) It metastasizes through blood or the lymphatic system. C) It begins as a small, waxy nodule with rolled translucent, pearly borders. D) It is a malignant proliferation arising from the epidermis.
C) It begins as a small, waxy nodule with rolled translucent, pearly borders BCC usually begins as a small, waxy nodule with rolled, translucent, pearly borders. It is less invasive than SCC. It does not metastasize through the blood or lymphatic system. SCC is a malignant proliferation arising from the epidermis.
The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? A) Administer diphenhydramine (Benadryl). B) Administer cimetidine (Tagamet). C) Measure the circumference of the arm. D) Assess peripheral pulses.
C) Measure the circumference of the arm Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is administered as an IV infusion whenever possible, although intramuscular administration can be used.
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects: A) squamous cell carcinoma. B) actinic keratoses. C) melanoma. D) basal cell carcinoma.
C) Melanoma The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma. Squamous cell carcinoma commonly develops on the skin of the face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas. Early lesions appear as opaque, firm nodules with indistinct borders, scaling, and ulceration. Actinic keratosis is a premalignant skin lesion. Basal cell carcinoma presents as lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated.
A patient is diagnosed with malignant melanoma that directly invades the adjacent dermis (vertical growth). The nurse knows that this type of melanoma has a poor prognosis. Which of the following is most likely the type of melanoma described in this scenario? A) Superficial spreading B) Lentigo-maligna C) Nodular melanoma D) Acral-lentiginous
C) Nodular melanoma A nodular melanoma is a spherical, blueberry-like nodule with a relatively smooth surface and a relatively uniform, blue-black color. A nodular melanoma invades directly into adjacent dermis (ie, vertical growth) and therefore has a poorer prognosis.
A patient is diagnosed with malignant melanoma that directly invades the adjacent dermis (vertical growth). The nurse knows that this type of melanoma has a poor prognosis. Which of the following is most likely the type of melanoma described in this scenario? A) Superficial spreading B) Lentigo-maligna C) Nodular melanoma D) Acral-lentiginous
C) Nodular melanoma A nodular melanoma is a spherical, blueberry-like nodule with a relatively smooth surface and a relatively uniform, blue-black color. A nodular melanoma invades directly into adjacent dermis (ie, vertical growth) and therefore has a poorer prognosis.
A young adult visits a health clinic for treatment of a severe case of eczema on his left leg. Which of the following is the preferred method for delivering medication in this scenario? A) Therapeutic bath B) Cream C) Ointment D) Topical anesthetic
C) Ointment Ointments retard water loss and lubricate and protect the skin. They are the preferred vehicle for delivering medication to chronic or localized dry skin conditions, such as eczema or psoriasis.
The nurse is assisting the physician with placing a ventricular assist device (VAD). Which assessment finding would confirm the successful implementation? A) Respiratory rate decreased B) Heart rate increased C) Pedal pulse stronger D) Temperature within normal limits
C) Pedal pulse stronger The ventricular assist device (VAD) is a medical mechanical device used to improve cardiac output and redistribute blood. The best evidence to confirm successful implementation is by identifying a strong pedal pulse in a lower extremity. Respiratory rate decreases as a client rests. Heart rate decreases when the tissues obtain the needed oxygen. The temperature within normal limits does not confirm successful implementation.
A patient is being treated for septic shock. On assessment, the nurse notes an abnormal finding that is reported to the health care provider. Which of the following is most likely that finding? A) CVP reading of 10 B) MAR reading of 65 mm Hg C) SVO2 of 55% D) Urinary output of 60 mL/hr
C) SVO2 of 55% Normal SVO2 values range from 60% to 80%. Lower values indicate inadequate tissue perfusion and the need for medical intervention.
A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? A) Laceration B) Avulsion C) Stab D) Patterned
C) Stab A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.
Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent? A)Cerium nitrate solution B) Gentamicin sulfate C) Sulfadiazine, silver (Silvadene) D) Mafenide (Sulfamylon)
C) Sulfadiazine, silver
The student nurse is completing a simulation where a client is the victim of nerve gas. The instructions are for the student to set up the room and have all needed supplies available. Which medication does the student nurse ensure is in the medication administration system to control seizures? A) Phenobarbital intramuscular B) Neurontin tablets C) Valium intravenous injection D) Dilantin tablets
C) Valium intravenous injection The students nurse is correct to have Valium intravenously on hand for seizure activity. When seizure activity occurs, the intravenous route is the best option to deliver the medication safely and rapidly into the system
The nurse has administered a subcutaneous injection of low-molecular-weight heparin to a patient who is recovering from surgery. This injection will be primarily deposited into: A) The epidermis B) The dermis C) Muscle D) Adipose tissue
D) Adipose tissue The subcutaneous tissue, or hypodermis, is the innermost layer of the skin. It is primarily adipose tissue, which provides a cushion between the skin layers, muscles, and bones.
During the acute phase of burn injury, the nurse knows to assess for signs of potassium shifting: A) Within 24 hours. B) Between 24 and 48 hours. C) At the beginning of the third day. ] D) Beginning on day 4 or day 5.
D) Beginning on day 4 or 5 Beginning on the fourth or fifth day, potassium shifts from the extracellular fluid into cells, and potassium deficit can occur during this phase.
Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? A) Mederma B) Integra C) Transcyte D) Biobrane
D) Biobrane Biobrane is a nylon-silicone membrane coated with a protein. Mederma ia a topical gel that can reduce scarring. Integra consists of a two-layer membrane: one is a synthetic epidermal layer , and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. Transcyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh.
The nurse is admitting a patient with a diagnosis of a gastrointestinal bleed who is in the compensatory stage of shock. Which of the following is an early sign that accompanies compensatory shock? A) Increased urine output B) Decreased heart rate C) Hyperactive bowel sounds D) Cool, clammy skin
D) Cool, clammy skin In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patient's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to A) increase metabolic rate. B) increase glucose demands. C) increase skeletal muscle breakdown. D) decrease catabolism.
D) Decrease catabolism The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? A) Complaints of intense thirst B) Moderate to severe pain C) Urine output of 70 ml the first hour D) Hoarseness of the voice
D) Hoarseness of the voice Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.
A nuclear reactor overheated, releasing radiation throughout the plant. A worker close to reactor received at least 800 rads and has had an onset of vomiting, bloody diarrhea, and, when brought to the hospital, was in shock. What is this patient's predicted survival? A) Possible B) Probable C) Likely D) Improbable
D) Improbable Improbable survivors have received more than 800 rad of total-body penetrating irradiation. People in this group demonstrate an acute onset of vomiting, bloody diarrhea, and shock. Any neurologic symptoms suggest a lethal dose of radiation (CDC, 2006). Possible survivors present with nausea and vomiting that persist for 24 to 48 hours. Probable survivors have either no initial symptoms or only minimal symptoms (e.g., nausea and vomiting), or these symptoms resolve within a few hours. "Likely" is not a survival category.
Which is a true statement regarding severe acute respiratory syndrome (SARS)? A) Constipation usually develops. B) It is spread by fecal contamination. C) Hypothermia will occur. D) It is most contagious during the second week of illness.
D) It is most contagious during the second week of illness Based on available information, SARS is most likely to be contagious only when symptoms are present, and clients are most contagious during the second week of illness. Diarrhea and hyperthermia may occur with SARS. Respiratory droplets spread the SARS virus when an infected person coughs or sneezes.
While performing an initial assessment of a patient, the nurse observes an elevated blue-black lesion on the patient's ear. The nurse knows that this is indicative of what type of skin cancer? A) Basal cell carcinoma B) Squamous cell carcinoma C) Dermatofibroma D) Malignant melanoma
D) Malignant melanoma A malignant melanoma presents itself as a superficial spreading melanoma, which may appear in a combination of colors, with hues of tan, brown, and black mixed with gray, blue-black, or white. The lesion tends to be circular, with irregular out portions. A dermatofibroma presents as a firm, done-shaped papule or nodule that may be skin colored or pinkish-brown. BCC usually begins as a small, waxy nodule with rolled, translucent, pearly borders; telangiectatic vessels may be present. SCC appears as a rough, thickened, scaly tumor that may be asymptomatic or may involve bleeding.
What laboratory value observed by the nurse is unexpected during the fluid remobilization phase of a major burn? A) Hematocrit level of 45% B) A pH of 7.20, PaO2 of 38 mm Hg, and bicarbonate level of 15 mEq/L C) Serum potassium level of 3.2 mEq/L D) Serum sodium level of 140 mEq/L
D) Serum sodium level of 140 mEq/L
A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? A) It helps determine the percentage of the total body surface area (TBSA) that is burned. B) The client's condition is likely to deteriorate after 72 hours. C) The wound is susceptible to infections. D) The early appearance of the burn injury may change.
D) The early appearance of the burn injury may change. The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.
A patient is in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse? A) "You don't want to remember your family member this way." B) "We have specific visiting hours that must be adhered to." C) "I will make arrangements for your family to be able to stay with the patient." D) "The healthcare team needs room to do procedures to help your family member, so it would be best if you stayed in the waiting area."
D) The healthcare team needs room to do procedures to help your family, so it would best if you stayed in the waiting area.
Which is defined as the potential of an agent to cause injury to the body? A) Volatility B) Latency C) Persistence D) Toxicity
D) Toxicity The median lethal dose (LD50) is the amount of the chemical that will cause death in 50% of those who are exposed. Persistence means that the chemical is less likely to vaporize and disperse. Volatility is the tendency for a chemical to become a vapor. Latency is the time from absorption to the appearance of symptoms.
When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications from shock. What does this require the nurse to do? A) Provide the family with realistic expectations around the patient's prognosis. B) Keep the health care provider updated with the most accurate information because during treatment of shock, the nurse is often powerless to help. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis, focusing on blood pressure and skin temperature. D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment and response.
D) Understanding the mechanisms of shock, recognize the subtle and more obvious signs. and then provide rapid assessment and response. Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse applies the nursing process as the guide for care. Shock is unpredictable and rapidly changing and the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the patient with the best chance for recovery. Setting the family's expectations is not a priority over patient care. Keeping the health care providers updated with the most accurate information is important but the nurse is in the best position to provide rapid assessment and response, giving the patient the best chance for survival. Monitoring for significant changes is critical and evaluating patient outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs such as blood pressure and skin temperature.
When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal? A) Improve the heart's pumping mechanism B) Limit further myocardial damage C) Preserve the healthy myocardium D) Treat the oxygenation needs of the heart muscle
D) treat the oxygenation needs of the heart muscle
