Exam 3: Questions

The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.

2 Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema. First-degree burn is another name for a superficial partial-thickness burn.

a nurse is examining a pt with anaphylactic shock. Which types of skin manifestations would the nurse expect to find? (select all) 1. Pallor 2. Pruritis 3. Flushing 4. Urticaria 5. Cold skin

2, 3, 4

Which intervention is included in the exposure and environmental control assessment component of the primary survey in the ED? 1. Securing the forehead to a backboard 2. Keeping the pt warm with blankets 3. Reassessing the LOC 4. Periodically performing a neuro exam

2. In the exposure / environmental control step, the pts clothes are removed for a thorough physical assessment. When the pt is exposed, warming blankets, and warmed IV fluids are used to limit heat loss, prevent hypothermis and maintain privacy.

The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock.

2. These client's signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased in- travascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stom- ach, which increases the risk of develop- ing ulcers, which can erode the stomach lining and lead to hemorrhaging.

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

22.5%

Which describes the primary purpose of administering 100% O2 to a pt with heatstroke? 1. Prevent dysrhythmias 2. Increase cerebral blood flow 3. Compensate for hypermetabolic state 4. Correct effects of an electrolyte imbalance

3

Which type of shock causes an absence of bowel sounds? 1. Neurogenic 2. Cardiogenic 3. Hypovolemic 4. Anaphylactic

3 (decreased bowel sounds = cardiogenic)

Which intervention does the nurse implement for the active external rewarming of a pt experiencing hypothermia? 1. Administer humidified O2 2. Remove pt wet clothing 3. Immerse pt in warm water 4. Place pt under radiant lighting

3 (humidified O2 is for active INTERNAL rewarming) (Passive rewarming - clothes and radiant lighting)

The nurse is monitoring a client for s/s of SVC syndrome. What is an early sign of this? 1. Cyanosis 2. Arm edema 3. Periorbital edema 4. Mental status change

3.

Which amount of fluid would the nurse anticipate incorporating into a patient's plan of care for fluid replacement due to septic shock? 1. 10 ml/kg 2. 30 3. 50 4. 70

30 of isotonic crystalloids (LR)

A patient is admitted with HL. Which assessment finding would the nurse expect to note specifically with this pt? 1. Fatigue 2. Weakness 3. Weight gain 4. Enlarged lymph nodes

4

Which physiologic change is associated with absolute hypovolemia? 1. Third spacing 2. Decreased afterload 3. Absent CO 4. Decreased venous return

4 (preload, not afterload, and CO are decreased)

Which action will the nurse take first to assess level of consciousness in a pt who has just been transported to the ED after an accident? 1. Touch the pt 2. Apply a painful stimulus 3. Call the pt by name 4. Observe the pt

4 (you want to observe for indications of alertness like opening their eyes to look around the room)

The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented? 1. Administer sliding-scale insulin as ordered. 2. Restrict caffeinated beverages. 3. Check urine ketones if blood glucose is >250. 4. Assess tissue turgor every four (4) hours.

4.

Which client problem is the nurse's priority concern for the client diagnosed with acute pancreatitis? 1. Impaired nutrition. 2. Skin integrity.3. Anxiety.4. Pain relief.

4.

The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Adequate peripheral circulation to both feet ensured.

4. The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes. Wounds should be covered with a clean, dry sheet.

The nurse is teaching about the s/s of hypercalcemia. What is a late sign of this? 1. HA 2. Dysphagia 3. Constipation 4. ECG changes

4. (shortened ST and wide T)

Which fluid increases osmotic pressure to provide rapid volume expansion for a pt with hypovolemic shock? 1. LR 2. 3% NaCl 3. FFP 4. Human serum albumin

4. It increases osmotic pressure and provides rapid volume expansion. LR and 3% NaCl are initial volume replacers for shock, but they do not provide rapid volume expansion

Which occurance causes gut bacteria to move into circulation in pts with SIRS? 1. Toxic effects of medicines 2. Effect of inflammatory mediators 3. Decreased GI motility 4. Decreased perfusion of gut mucosa

4. There is a breakdown of the protective mucosal barrier --> bacteria can move from GI tract into circultation

A nurse is caring for a patient newly diagnosed with type 1 diabetes. The nurse is educating the patient about self-administration of insulin in the home setting. The nurse should teach the patient to do which of the following? A) Avoid using the same injection site more than once in 2 to 3 weeks. B) Avoid mixing more than one type of insulin in a syringe. C) Cleanse the injection site thoroughly with alcohol prior to injecting. D) Inject at a 45 angle.

A

An 83-year-old patient is brought in by ambulance from a long-term care facility. The patients symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true? A) Older adults may have an altered response to treatment. B) Older adults are often reluctant to adhere to prescribed treatment. C) Older adults have difficulty giving a health history. D) Older adults often stigmatize their peers who use the ED.

A

The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurses assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary conclusion? A) The patient is in the compensatory stage of shock. B) The patient is in the progressive stage of shock. C) The patient will stabilize and be released by tomorrow. D) The patient is in the irreversible stage of shock.

A

The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2C (91.8F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurses priority in the care of this patient? A) Addressing the patients hypothermia B) Addressing the patients frostbite in his lower extremities C) Addressing the patients alcohol intoxication D) Addressing the patients malnutrition

A

A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? A) Control the patients hemorrhage. B) Assess for cognitive effects of the injury. C) Splint the patients fractures. D) Assess the patients neurologic status.

A After establishing airway and ventilation, the team should evaluate and restore cardiac output by controlling hemorrhage. This must precede neurologic assessments and treatment of skeletal injuries.

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) 1 week

A Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism (VTE)

A As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site.

The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock? A) Lactated Ringers B) Albumin C) Dextran D) 3% NaCl

A Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringers and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. 3% NaCl is a hypertonic solution and is not isotonic.

A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patients frostbite? A) Immerse affected extremities in water slightly above normal body temperature. B) Immerse the patients frostbitten extremities in the warmest water the patient can tolerate. C) Gently massage the patients frozen extremities in between water baths. D) Perform passive range-of-motion exercises of the affected extremities to promote circulation.

A Frozen extremities are usually placed in a 37C to 40C (98.6F to 104F) circulating bath for 30- to 40- minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

A patient has been brought to the emergency department by paramedics after being found unconscious. The patients Medic Alert bracelet indicates that the patient has type 1 diabetes and the patients blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? A) IV administration of 50% dextrose in water B) Subcutaneous administration of 10 units of Humalog C) Subcutaneous administration of 12 to 15 units of regular insulin D) IV bolus of 5% dextrose in 0.45% NaCl

A In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia. Five percent dextrose would be inadequate and insulin would exacerbate the patients condition.

A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident.

A Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care teams responsibility to determine the circumstances of the accident.

You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient? A) Hypothermia B) Bradycardia C) Coffee ground emesis D) Pain

A Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the patient for cardiovascular overload and pulmonary edema when large volumes of IV solution are administered. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to cardiogenic shock.

The nurse is caring for a patient in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications? A) Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration B) Reviewing medications, performing a focused cardiovascular assessment, and providing patient education C) Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema D) Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions

A When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump should be used to ensure that the medications are delivered safely and accurately. Individual medication dosages are usually titrated by the nurse, who adjusts drip rates based on the prescribed dose and the patients response.

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female patient burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

A Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient

An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A) The causative agent B) The patients preinjury health status C) The patients prognosis for recovery D) The circumstances of the accident

A (this is the etiology of the burn, which is one of the characteristics)

The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply. A)Drop in systolic blood pressure of 40 mm Hg from baselines B) Hypotension that responds to bolus fluid resuscitation C) Exaggerated response to vasoactive medications D) Serum lactate >4 mmol/L E) Mean arterial pressure (MAP) of 65 mm Hg

A, D, E

A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A) Check the patients blood glucose level. B) Assess for a documented history of major depression. C) Determine whether the patient has ingested a corrosive substance. D) Arrange for assessment of serum potassium levels.

A. Hypoglycemia can mimic alcohol intoxication and should be assessed in a patient suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication.

The nurse is caring for a 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.Incorrect Answer 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

A diabetic patient calls the clinic complaining of having a flu bug. The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient? A) Make sure to stick to your normal diet. B) Try to eat small amounts of carbs, if possible. C) Ensure that you check your blood glucose every hour. D) For now, check your urine for ketones every 8 hours.

B For prevention of DKA related to illness, the patient should attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.

The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom? A) Hypertension with a wide pulse pressure B) Anhidrosis C) Copious diuresis D) Cheyne-Stokes respirations

B Heat stroke is manifested by anhidrosis confusion, bizarre behavior, coma, elevated body temperature, hot dry skin, tachypnea, hypotension, and tachycardia.

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patients initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patients fluid balance C) Assessing the patients level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolism

B In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the patient for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority.

A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing? A) Anaphylactic shock B) Neurogenic shock C) Septic shock D) Hypovolemic shock

B Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation.

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member? A) He's on a calorie-restricted diet in order to divert energy to wound healing. B) His body has consumed his fat deposits for fuel because his calorie intake is lower than normal. C) He actually hasnt lost weight. Instead, theres been a change in the distribution of his body fat. D) He lost many fluids while he was being treated in the emergency phase of burn care.

B Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Patients are not placed on a calorie restriction during recovery and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur.

A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patients health problem? A) Blood is shunted from vital organs to peripheral areas of the body. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.

B Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.

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

The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments? A) Temperature and oxygen saturation B) Heart rate and BP C) Breath sounds and bowel sounds D) Color, warmth, movement, and sensation of extremities

B The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The patients condition needs to be monitored frequently during the test, and the test is terminated if tachycardia, excessive weight loss, or hypotension develops. Consequently, BP and heart rate monitoring are priorities over the other listed assessments.

A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? Select all that apply. A) Leukocytosis B) Glycosuria C) Dehydration D) Hypernatremia E) Hyperglycemia

B, C, D, E In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur. Leukocytosis does not take place.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A) Obtain an order to reduce the rate of the patients IV fluid infusion. B) Report the patients early signs of acute kidney injury (AKI). C) Recognize that the patient is experiencing an expected onset of diuresis. D) Administer sodium chloride as ordered to compensate for this fluid loss.

C As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.

A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) During waking hours for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury

C Elastic pressure garments are worn continuously (i.e., 23 hours a day).

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.

C Endotracheal tubes are used in cases when the patient cannot be ventilated with an oropharyngeal airway, which is used in patients who are breathing spontaneously. The jaw thrust maneuver does not establish an airway and cricothyroidotomy would be performed as a last resort.

A critical care nurse is aware of similarities and differences between the treatments for different types of shock. Which of the following interventions is used in all types of shock? A) Aggressive hypoglycemic control B) Administration of hypertonic IV fluids C) Early provision of nutritional support D) Aggressive antibiotic therapy

C Nutritional support is necessary for all patients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many patients. Hypertonic IV fluids are not normally utilized and antibiotics are necessary only in patients with septic shock.

A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B) Place the patient in a high Fowlers position. C) Immobilize the patient on a backboard. D) Place the patient in a left lateral position.

C When admitted for blunt trauma, patients must be immobilized until spinal injury is ruled out. Ambulation, side-lying, and upright positioning would be contraindicated until spinal injury is ruled out.

Pallor, cold and clammy skin changes = what types of shock?

Cardiogenic Hypovolemic Obstructive

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patients affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.

D Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain, and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Butter is contraindicated.

Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression. As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring? A) Urinary output increases B) Skin becomes warm and dry C) Adventitious lung sounds occur in the upper airway D) Heart and respiratory rates are elevated

D Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.

The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient? A) It promotes coping and slows catecholamine release. B) It stimulates the patient so he or she is more alert. C) It decreases gastric secretions. D) It dilates the blood vessels.

D For patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patients anxiety.

The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A) Increased urine output B) Decreased heart rate C) Hyperactive bowel sounds D) Cool, clammy skin

D 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 patients 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.

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A) Maintenance of bed rest to aid healing B)Choosing appropriate splints and functional devices C) Administration of beta adrenergic blockers D) Prevention of venous thromboembolism

D Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patients daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of antihypertensive medications B) Administering sodium bicarbonate intravenously C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement

D The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration.

A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second- and third-degree burns, but he is conscious. How would this person be triaged? A) Green B) Yellow C) Red D) Black

D The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. The patient would be triaged as black due to the unlikelihood of survival. Persons triaged as green, yellow, or red have a higher chance of recovery.

A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? A) 13% B) 25% C) 9% D) 18%

D When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.

A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1C (104.2F). What would be the priority nursing action for this patient? Monitor cardiovascular effect Administer antipyretics. Ensure airway and ventilation. Prevent seizure activity.

Ensure airway and ventilation. Although all of the listed actions may be necessary for this patients care, the priority is to establish a patent airway and adequate ventilation.

A pt presents to the ED with a life threatening illness. When monitoring the patient's condition during the primary survey, the nurse preforms which resuscitation adjunct measures? (select all) 1. Inspect chest 2. Obtain lab tests 3. Assess pt pain 4. Insert NG tube 5. Monitor ECG 6. Continuous O2 monitoring

Everything but inspect chest (that is done in the secondary survey)

Which type of shock is associated with electrolyte imbalances and decreased hgb and hct?

Hypovolemic

A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? Absence of bruising at contusion sites Rapid pulse and decreased capillary refill Increased BP with narrowed pulse pressure Sudden diaphoresis

Rapid pulse and decreased capillary refill

Which type of shock is associated with increased levels of glucose, lactate, postive blood cultures?

Septic

The patient is receiving an IV vesicant chemotherapy drug. The nurse notices swelling and redness at the site. What should the nurse do first? Ask the patient if the site hurts. Turn off the chemotherapy infusion. Call the ordering health care provider. Administer sterile saline to the reddened area.

Turn off the chemotherapy infusion. Because extravasation of vesicants may cause severe local tissue breakdown and necrosis, with any sign of extravasation, the infusion should first be stopped. Then the protocol for the drug-specific extravasation procedures should be followed to minimize further tissue damage. The site of extravasation usually hurts, but it may not. It is more important to stop the infusion immediately. The health care provider may be notified by another nurse while the patient's nurse starts the drug-specific extravasation procedures, which may or may not include sterile saline.

Which color tag would be used in an MCI for a pt who reports severe pain and has an open fracture to the leg with a BP of 160/90 and a pulse of 90?

Yellow

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient? a) Assessing the patients oral temperature frequently b) Ensuring continuous ECG monitoring c) Massaging the patients skin surfaces to promote circulation d) Administering bronchodilators by nebulizer

b A hypothermic patient requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not performed and bronchodilators would normally be insufficient to meet the patients respiratory needs.

Maintaining an open airway is a supportive therapy for ________ and ________ shock

neurogenic and anaphylactic

The nurse is caring for an 18-yr-old patient with acute lymphocytic leukemia who is scheduled for hematopoietic stem cell transplantation (HSCT). Which patient statement indicates a correct understanding of the procedure? "I understand the transplant procedure has no dangerous side effects." "After the transplant, I will feel better and can go home in 5 to 7 days." "My brother will be a 100% match for the cells used during the transplant." "Before the transplant, I will have chemotherapy and possibly full-body radiation."

"Before the transplant, I will have chemotherapy and possibly full-body radiation." Hematopoietic stem cell transplantation (HSCT) requires eradication of diseased or cancer cells. This is accomplished by administering higher-than-usual dosages of chemotherapy with or without radiation therapy.

Which assessment findings are associated with heat exhaustion? (select all) 1. Dilated pupils 2. Tachy 3. HTN 4. Flushed skin 5. Muscle contractions

1, 2 Muscle contractions = heat cramps Hypotension + ASHEN color skin

Which manifestations of compensatory stage of the resp system in pts with shock? (select all) 1. Tachypnea 2. Hyperventilation 3. Severe hypoxemia 4. Pulmonary vasoconstriction 5. Pulmonary interstitial edema

1, 2 (pulmonary vasoconstriction and edema are part of the progressive stage)

Vasopressor agent are prescribed for which types of shock? (select all) 1. Septic 2. Neurogenic 3. Obstructive 4. Cardiogenic 5. Hypovolemic

1, 2 Septic shock leads to release of cytokines and inflammatory mediators, which leads to vasodilation and increased capillary permeability and platelet agg. Vasopressors constrict blood vessels and help relieve hypotension. Neurogenic shock needs Vasopressors because of the loss of sympathetic stimulation of blood vessels.

Which actions will the nurse anticipate for the pt who has been working outside on a hot day and is now minimally responsive and has hypotension, body temp of 106? (select all) 1. Administer 100% O2 2. Immerse in a cool bath 3. Administer cool IV fluids 4. Cover the pt with light blankets 5. Administer acetaminophen

1, 2, 3 Acetaminophen won't be effective because the increase in temp is not related to infection or problems with the hypothalamic set point for temp

The nurse anticipates which clinical findings in a pt with anayphylactic shock? (select all) 1. Stridor 2. Pruritis 3. Anxiety 4. Pallor 5. Chest pain

1, 2, 3, 5 (you would have skin flushing, not pallor)

Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply .1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change invasive lines once a week. 5. Administer antibiotics as prescribed.

1, 2, 3, 5 Aseptic techniques minimize risk of cross- contamination and spread of bacteria. Aseptic techniques minimize risk of cross- contamination and spread of bacteria. Invasive lines and tubing should be changed daily. Antibiotics reduce bacteria.

The nurse is caring for a pt with lung cancer and bone mets. What s/s would the nurse recognize as indications of a possible onc emergency? (select all): 1. Facial edema in the morning 2. Weigh loss of 20 lbs in 1 month 3. Serum Ca level of 12 4. Serum Na level of 136 5. Serum K level of 3.4 6. Numbness and tingling in the lower extremities

1, 2, 3, 6

The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply. 1. Restrict fluids per health-care provider order. 2. Assess level of consciousness every two (2) hours. 3. Provide an atmosphere of stimulation. 4. Monitor urine and serum osmolality. 5. Weigh the client every three (3) days.

1, 2, 4

The nurse provides care for a pt who is suspected of having a SCI and is immobilized with a cervical collar. Which initial actions does the nurse take during the primary survey of this pt? (select all) 1. Administer O2 2. Monitor airway patency 3. Initiate IV lines 4. Maintain pt in supine position 5. Prep pt for rapid sequence intubation

1, 2, 4

What types of shock cause reduced UO? (Select all) 1. Septic 2. Obstructive 3. Neurogenic 4. Cardiogenic 5. Hypovolemic 6. Anaphylactic

1, 2, 4, 5 Neurogenic --> bladder dysfunction Anaphylactic --> urinary incontinence

The nurse is conducting a history and monitoring the lab values on a pt with MM. What assessment findings should the nurse expect to note? (select all): 1. Pathological fracture 2. Urinalysis positive for nitrites 3. Hgb of 15 4. Ca of 8.6 5. Serum creatinine of 2.0

1, 2, 5

Which are considered late signs of septic shock? *select all 1. Cool skin 2. Mottled skin 3. Resp alkolosis 4. AMS 5. Myocardial dysfunction

1, 2, 5 The cool skin is d/t microthrombi and loss of circultation

Which conditions can cause hypovolemic shock (select all): 1. Ruptured spleen 2. Vavular stenosis 3. Bowel obstruction 4. DI 5. Tension Pneumothorax

1, 3, 4 (Bowel obstruction leads to relative hypovolemic shock)

A gastric lavage has been ordered for a client who is comatose and who ingested a full bottle of acetaminophen, a nonnarcotic analgesic. Which intervention should be included in the procedure? Select all that apply. 1. Place the client on the left side with the head 15 degrees lower than the body. 2. Insert a small-bore feeding tube into the naris. 3. Have standby suction available. 4. Withdraw stomach contents and then instill an irrigating solution. 5. Send samples of the stomach contents to the lab for analysis.

1, 3, 4, 5

Which assessment findings does the nurse expect for a pt in early septic shock? (select all) 1. Crackles 2. Coma 3. Decreased UO 4. Cool/mottled skin 5. HR of 120 bpm

1, 3, 5

While in the ED a pt dies. What action does the nurse take when initially approaching the pts family? (select all) 1. Provide Support 2. Inquire about organ donation 3. Gather the pts belongings 4. Discuss mortuary arrangements 5. Provide family members with a place of privacy

1, 5 (these are the most initial things a nurse would do, the others would occur later)

The nurse is creating a plan of care ofr a pt with MM. What is the priority intervention? 1. Encourage fluids 2. Provide freq oral care 3. Coughing and deep breathing 4. Monitor RBC count

1.

Which goal for fluid resucitation would the nurse choose when caring for a pt with sepsis 1. Restore tissue perfusion 2. Increase circulating fluid volume 3. Restore blood flow to the myocardium 4. Maintain a MAP of 50

1.

The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing? 1. The hypodynamic phase. 2. The compensatory phase. 3. The hyperdynamic phase. 4. The progressive phase.

1. The hypodynamic phase is the last and irreversible phase of septic shock, char- acterized by low cardiac output with vasoconstriction. It reflects the body's effort to compensate for hypovolemia caused by the loss of intravascular volume through the capillaries.