GG

Surface area for groin

1%

Surface area for entire left leg

18% A and P = 9%

Surface area for entire right leg

18% A and P = 9%

Surface area for entire trunk

36% A and P = 18%

Surface area for entire left arm

9% A and P = 4.5%

Surface area for entire right arm

9% A and P = 4.5%

Surface burn area for entire head

9% A and P = 4.5%

B. Applying a cold pack to the injured site

A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action? A. Taking an opioid analgesic as prescribed B. Applying a cold pack to the injured site C. Performing passive ROM exercises D. Applying a heating pad to the affected muscle

D. Airway management

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. Pain B. Fluid balance C. Anxiety and fear D. Airway management

3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water

d.Decompensation

A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur? a.Compensation b. b.Irreversible c.Early d.Decompensation

C. Trim away the separated xenograft.

A client with a partial-thickness burn injury had a xenograft applied 2 weeks ago. The nurse notices that the xenograft is separating from the burn wound. What is the nurse's most appropriate intervention? A. Reinforce the xenograft dressing with another piece of Biobrane. B. Remove the xenograft dressing and apply a new dressing. C. Trim away the separated xenograft. D. Notify the health care provider for further emergency-related orders.

C. Decreased blood pressure

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? A. Confusion B. High fever C. Decreased blood pressure D. Sudden agitation

B. Inform the primary care provider promptly because the graft may need to be removed.

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A. Perform mechanical débridement to remove the exudate and prevent further infection. B. Inform the primary care provider promptly because the graft may need to be removed. C. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. D. Document this finding as an expected phase of graft healing.

Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nuts Septic shock; infection

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply.

A. A 4-year-old scald victim burned over 24% of the body

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which client 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 client burned over 18% of her body D. A 60-year-old male burned over 16% of his body in a brush fire

B. Neurogenic shock

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

c. Chest petechiae

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? a. Ecchymosis of the thigh b. Serous drainage at the pin site c. Chest petechiae d. Muscle spasms in the left leg

C. Provide a fan to blow cool air into the cast to relieve itching.

A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A. Allow the client to gently scratch inside the cast with a pencil. B. Give the client a sterile tongue depressor to use for scratching instead of the pencil. C. Provide a fan to blow cool air into the cast to relieve itching. D. Obtain a prescription for a sedative, such as lorazepam, to prevent the client from scratching.

turning from side to side

A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions?

A) Encouraging the patient to turn from side to side and to assume a prone position

A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day

C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists.

A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A) Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious. B) Give the patient a sterile tongue depressor to use for scratching instead of the pencil. C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists. D) Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.

a. Disturbed body image

A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patient's postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care? a. Disturbed body image b. Risk Prone Health Behavior c. Ineffective Thermoregulation d. Defiencient Diversion Acitivty

A) Obstructed arterial blood flow to the forearm and hand

A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication? A) Obstructed arterial blood flow to the forearm and hand B) Simultaneous pressure on the ulnar and radial nerves C) Irritation of Merkel cells in the patient's skin surfaces D) Uncontrolled muscle spasms in the patient's forearm

d) The patient is at risk for developing hypovolemic shock

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a) The assessed values are within normal limits b) The patient is at risk for developing cardiogenic shock c) The patient is at risk for developing fluid volume overload d) The patient is at risk for developing hypovolemic shock

c. 938 mL/hr

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. the initial volume of fluid to be given in the first 24 hours is 30,000 mL. the initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate would the nurse infuse theIV fluids? a. 219 mL/hr b. 625 mL/hr c. 938 mL/hr d. 1875 mL/hr

A. Anaphylactic D. Septic E. Neurogenic

A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses identify? Select all that apply. A. Anaphylactic B. Hypovolemic C. Cardiogenic D. Septic E. Neurogenic

d. A 74-year-old man who smokes and has a fractured pelvis

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year old female with type 2 diabetes and fractured ribs c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis d. A 74-year-old man who smokes and has a fractured pelvis

4) Carboxyhemoglobin level

A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if this patient is experiencing carbon monoxide poisoning? 1) Chest x-ray 2) Bronchoscopy 3) Pulse oximeter 4) Carboxyhemoglobin level

3) Singed facial hair

A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury? 1) Coughing 2) Soot on the face 3) Singed facial hair 4) Heart rate 98 bpm

2)Prepare for blood transfusions 3)Prepare for emergency surgery 4)Assess for active hemorrhaging 5)Monitor effectiveness of tourniquet

A victim of a motor vehicle crash has a partially severed lowered extremity. What emergency care does this patient need? Select all that apply. 1) Administer antibiotics 2) Prepare for blood transfusions 3) Prepare for emergency surgery 4) Assess for active hemorrhaging 5) Monitor effectiveness of tourniquet

A. Administer IV fluids.

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A. Administer IV fluids. B. Administer broad-spectrum antibiotics. C. Administer IV potassium chloride. D. Administer packed red blood cells.

1500 mL/hr

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

333 drops/min

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

3) Establishing invasive cardiac monitoring

An older adult patient is experiencing hypovolemic shock. Which is the priority intervention for this patient? 1) Assessing the cause of bleeding 2) Providing replacement of volume 3) Establishing invasive cardiac monitoring 4) Administering analgesics for control of pain

singed nose hairs probably

How to know if someone inhaled hot air or not?

A. Fluid volume circulating in the blood vessels decreases.

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances?' A. Fluid volume circulating in the blood vessels decreases. B. There is an uncontrolled increase in cardiac output. C. Blood pressure regulation becomes irregular. D. The client experiences tachycardia and a bounding pulse.

compensatory

In what stage of shock is the body able to compensate with vasoconstriction, have a low-normal BP, and still perfuse to the vital organs?

1) Auscultate breath sounds for crackles

The nurse is administering albumin 5% to a patient in shock. Which nursing action is appropriate when assessing this patient? 1) Auscultate breath sounds for crackles 2) Auscultate breath sounds for hyperresonance 3) Auscultate breath sounds for inspiratory stridor 4) Auscultate for an absence of breath sounds in the lower lobes

A) Through a central venous line

The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The nurse should know that vasoactive medications should be administered in what way? A) Through a central venous line B) By a gravity infusion IV set C) By IV push for rapid onset of action D) Mixed with parenteral feedings to balance osmosis

C. Bradycardia

The ICU nurse is caring for a client in neurogenic shock following an overdose of antianxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock? A. Hypertension B. Cool, moist skin C. Bradycardia D. Signs of sympathetic stimulation

D. Maintenance of adequate mean arterial pressure

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify? A. Absence of infarcts or emboli B. Reduced stroke volume and cardiac output C. Absence of pulmonary and peripheral edema D. Maintenance of adequate mean arterial pressure

D. Cool, clammy skin

The emergency nurse is admitting a client 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

a. Assessing and identifying clients at risk c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

A. The client is in the compensatory stage of shock.

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

A. Lactated Ringer

The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer? A. Lactated Ringer B. Albumin C. Dextran D. 3% NaCl

a) BP c) LOC f) urine output

The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply). a) BP b) HR c) LOC d) Pupil response e) Respirations f) Urine output

3) Increased potassium

The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected? 1) Increased pH 2) Increased sodium 3) Increased potassium 4) Decreased hematocrit

C. Tachycardia

The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will increase the client's cardiac output during the hypovolemic state? A. Third spacing of fluid B. Dysrhythmias C. Tachycardia D. Gastric hypermotility

2) Notifying the Rapid Response Team

The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic, hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient? 1) Starting two large intravenous catheters 2) Notifying the Rapid Response Team 3) Calling the patient's physician to report the changes 4) Placing oxygen on the patient

1. The patient reports pain 3. The patient reports numbness. 5. The patient reports a feeling of pressure.

The nurse monitors for which clinical manifestations in the patient with suspected compartment syndrome? Select all that apply. 1. The patient reports pain. 2. The patient's limb is red. 3. The patient reports numbness. 4. The patient's pulses are bounding. 5. The patient reports a feeling of pressure.

Fat embolism

The nurse observes a petechial rash and respiratory distress in a patient recovering from a fractured femur. What should these findings suggest to the nurse? Infection Pneumonia Fat embolism Pleural effusion

B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!"

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? A. Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C. An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D. Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

A) Burns

The nurse recognizes the patient with which condition is at greatest risk for hypovolemic shock? A) Burns B) Sepsis C) Pericarditis D) Myopathies

1) Never leave a burning candle unattended. 3) Keep a flashlight and telephone near the bed. 4) Check smoke alarm batteries every six months. 5) Never use the oven as a method to warm the home

The school nurse is preparing material for National Fire Prevention week. What information should be added to the classroom posters? Select all that apply. 1) Never leave a burning candle unattended. 2) Set heating pads on "low" when sleeping. 3) Keep a flashlight and telephone near the bed. 4) Check smoke alarm batteries every six months. 5) Never use the oven as a method to warm the home

RICE (rest, ice, compression, elevation) - immobilize - anti-inflammatory medications

What do we do for a strain and sprain?

irreversible

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis?

progressive

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg?

The client is not responding to medical interventions.

You are talking with the family of a client who is in the irreversible stage of shock. They ask you why the physician has told the family that the client is going to die. What would you explain to this family?

circulatory shock state resulting from severe allergic reaction producing acute systemic vasodilation, relative hypovolemia.

anaphylactic shock

a graft derived from one part of a patient's body and used on another part of that same patient's body

autograft

shock state resulting from impairment or failure of myocardium.

cardiogenic shock

Pale, cold, clammy skin. Shallow, rapid breathing. Difficulty breathing. Anxiety.

common symptoms of shock?

cool, clammy skin, decreased cardiac output, increased HR

common symptoms of shock?

removal of foreign material and devitalized tissue until surrounding healthy tissue is exposed

debridment

a linear excision made through eschar to release constriction of underlying tissue

escharotomy

surgical removal of tissue

excision

an incision made through the fascia to release constriction of underlying muscle

fasciotomy

a graft transferred from one human (living or cadaveric) to another human (synonym: allograft)

homograft

shock state resulting from decreased intravascular volume due to fluid sloss.

hypovolemic shock

shock state resulting from loss of sympathetic tone causing relative hypovolemia.

neurogenic shock

circulatory shock state resulting from acute infection causing relative hypovolemia

septic shock

b. duodenal tube feedings

the nurse is caring for a patient with 70% total body surface area chemical burns. which approach should the nurse anticipate to meet this patients nutritional needs a. parenteral nutrition b. duodenal tube feedings c. nasogastric tube feedings d. six small high caloric meals per day

d. urine output 800 ml over 2 hours

the nurse is caring for a pt with 50% total body surface area burns. which finding indicates that burn shock is resolving a. HR 112 BPM b. respirations 24 per minute c. BP 90/60 d. urine output 800 ml over 2 hours

a graft obtained from an animal of a species other than that of the recipient (e.g., pigskin) (synonym: heterograft)

xenograft