HCC 4.5 Practice Qs

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? 1 Have patients wear masks in the health care facility. 2 Insert indwelling catheters for incontinent patients. 3 Administer prophylactic antibiotics for all patients at risk. 4 Use strict hand hygiene techniques.

4

A patient is admitted to the hospital with acute rejection of a kidney transplant. The nurse will anticipate a. administration of immunosuppressant medications. b. insertion of an arteriovenous graft for hemodialysis. c. placement of the patient on the transplant waiting list. d. drawing blood for human leukocyte antigen (HLA) and ABO compatibility matching.

A

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which of the following would cause the nurse to suspect that the client has early shock? A. Hypotension B. Bradypnea C. Irregular heart rhythm D. Tachycardia

A

The nurse plans long-term goals for the patient who has had a heart transplant with the knowledge that a common cause of death in heart transplant patients during the first year is: a. infection b. heart failure. c. embolization d. malignant conditions

A

The nurse uses topical gentamicin sulfate (Garamycin) on a client's burn injury. Which laboratory value will the nurse monitor? A. Creatinine B. Red blood cells C. Sodium D. Magnesium level

A Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. In burn patients, the systemic absorption of topical gentamicin may be enhanced, and one should be watchful for the potential repercussions.

A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply.) A. Western blot B. Indirect immunofluorescence assay C. CD4+ T‑lymphocyte count D. HIV RNA quantification test E. Cerebrospinal fluid (CSF) analysis

A, B

A nurse is assessing a client who has end‑stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply.) A. Anuria B. Marked azotemia C. Crackles in the lungs D. Increased calcium level E. Proteinuria

A, B, C, E

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

A,C,F Some facilities restrict consumption of fresh vegetables due to the presence of bacteria on the surface and the increased risk for infection. The client should consume up to 5,000 calories/day because caloric needs double or triple beginning 4 to 12 days following the burn.

How does the nurse recognize that the client with septic shock has severe tissue hypoxia? A. PaCO2 58mm Hg B. Lactate level 9.0mmol/L C. INR 1.6 D. Potassium 2.8mEq/mL

B

The nurse provides dietary teaching for a client who is diagnosed with AIDS. Which client statement indicates a correct understanding of the information presented by the nurse? 1 "I will be sure to eat my eggs before my toast at breakfast." 2 "I will eat three large meals a day." 3 "I will choose french fries instead of a baked potato for dinner tonight." 4 "I will use an alcohol-based mouthwash twice per day."

1

The phone triage nurse answers a call from a client who reports having a positive enzyme-linked immunosorbent assay (ELISA) test for HIV. The client anxiously asks the nurse to explain what this means. How does the nurse respond? 1 "You will need a follow up blood test to help interpret your ELISA test results." 2 "A Western blot test should be performed next." 3 "The ELISA test provides information about the viral load." 4 "This test indicates it is probable that you have acquired immunodeficiency syndrome, or AIDS."

1

The intensive care unit nurse is caring for a patient who is ventilated mechanically. To prevent sepsis in this patient, which nursing intervention does the nurse include in the plan of care? 1 Provide oral care every two to four hours. 2 Turn patient from side to side every eight hours. 3 Position patient in a supine position every two hours. 4 Use clean gloves when suctioning the endotracheal tube.

1 Because research has found that the oral flora of critically ill patients are predominately gram-negative organisms that can potentially cause ventilator-associated pneumonia. Oral care will help reduce the organisms.

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) 1 Urinary output 2 Mental status 3 Vital signs 4 Ability to perform range of motion exercises 5 Visual acuity

1, 2, 3

The nurse assesses a client who recently underwent a kidney transplant. Which signs of transplant rejection does the nurse report to the healthcare provider?Select All That Apply 1 Lower extremity edema 2 Fever 3 Myalgia 4 Weight gain 5 Polyuria

1, 2, 3, 4

A nurse provides discharge instructions to a client with human immunodeficiency virus (HIV). Which instructions does the nurse provide? Select All That Apply 1 "Avoid being around individuals with symptoms of contagious infections." 2 "Do not share your shaving razor or nail clippers with anyone." 3 "Sexual partners should be tested for human immunodeficiency virus." 4 "Avoid sharing drinks or utensils with healthy family members." 5 "Use condoms consistently and correctly for vaginal or anal sex."

1, 2, 3, 5

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? 1 A slow and imperceptible pulse 2 A rapid, bounding pulse 3 A weak and thready pulse 4 A slow but steady pulse

2

Which information does the nurse include when providing teaching to a female client with human immunodeficiency virus (HIV) who wants to get pregnant?Select All That Apply 1 "You must have a cesarean birth because labor and delivery present too high a risk." 2 "Your partner is at risk while not using barrier birth control and should consider prophylaxis treatment." 3 "Stop taking antiretroviral drugs during your pregnancy, particularly the last trimester." 4 "The baby could be exposed to HIV during birth, a risk that is reduced with anti-HIV drugs." 5 "HIV can pass through the placenta or be transmitted after the amniotic sac breaks."

2, 4, 5

A patient's localized infection has progressed to the point where septic shock now is suspected. What medication is an appropriate treatment modality for this patient? 1 Insulin infusion 2 Intravenous (IV) administration of epinephrine 3 Aggressive IV crystalloid fluid resuscitation 4 Administration of nitrates and β-adrenergic blockers

3

A nurse cares for a pregnant client who has been diagnosed with human immunodeficiency virus (HIV). Which statement is true regarding risk of transmission from mother to child? 1 Taking HIV medications during labor eliminates the risk of transmission. 2 Mothers who are HIV positive can still safely breastfeed. 3 The virus can be transferred in utero through the placenta. 4 After rupture of membranes in labor, the risk of transfer increases. 5 The virus can be transferred into the amniotic fluid during the pregnancy.

3, 4

The nurse cares for a heart transplant recipient. The nurse administers which medications to the client? 1 Divalproex sodium 2 Metoclopramide 3 Furosemide 4 Mycophenolate mofetil 5 Prednisone

3, 4, 5

The nurse is caring for an older adult client with a urinary tract infection (UTI). Per sequential organ failure assessment (SOFA) criteria, which findings does the nurse apply as evidence the client may have urosepsis? 1 Persistent oral temperature of ≥ 99.0° F (37.2° C) 2 New onset of urinary incontinence 3 Respiratory rate of 26 breaths/min. 4 Increase in total urine output volume 5 Change in oxygen saturation from 98% to 93%

3, 5

An intensive care unit nurse monitors a client with sepsis. Lab values include decreased hemoglobin, hematocrit, fibrinogen, and platelet levels. Which complication does the nurse suspect? 1 Bone marrow depression 2 Systemic inflammatory response syndrome 3 Hypovolemic shock 4 Disseminated intravascular coagulation

4

The nurse assesses the client's central line insertion site is red and warm. The client's temperature is 101.3 °F (38.5 °C). A diagnosis of sepsis is confirmed. Which result alerts the nurse that the client may have septic shock? 1 elevated activated protein C 2 elevated white blood cell count 3 normal to low serum lactate level. 4 elevated blood glucose level

4

The nurse cares for a client in the emergency department with generalized malaise and a sacral ulcer with purulent drainage. The nurse alerts the healthcare provider (HCP) of suspected sepsis after noting which signs? 1 Mean arterial pressure of 72 mm Hg and a falling creatinine level 2 Respiratory rate of 8 breaths/min and low blood glucose 3 Heart rate of 63 beats/min and platelet count 550,000/mm3 4 The temperature of 101.5°F (38.6°C) and elevated lactic acid levels

4

Which sign of neurologic dysfunction is commonly seen in both systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? 1 Increased heart rate 2 Increased liver enzymes 3 Difficulty breathing 4 Confusion, agitation, and lethargy

4

The nursing assistant reports concerns about the postoperative client who has BP 90/60, HR 80, R 22. What should the RN do? A. Compare these VS with last several readings B. Request that the surgeon come see the client C. Increase the rate of IV fluids D. Reassess VS using different equipment

A

Ten hours after the client with 50% burns is admitted, her blood glucose level is 142 mg/dL. What is the nurse's best action? A. Documents the finding B. Obtains a family history of diabetes C. Repeats the glucose measurement D. Stop IV fluids containing dextrose

A Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.

A nurse is teaching a client who is scheduled for a kidney transplant about organ rejection. Which of the following statements should the nurse include? (Select all that apply.) A. "Expect an immediate removal of the donor kidney for a hyperacute rejection." B. "You might need to begin dialysis to monitor your kidney function for a hyperacute rejection." C. "A fever is a manifestation of an acute rejection." D. "Fluid retention is a manifestation of an acute rejection." E. "Your provider will increase your immunosuppressive medications for a chronic rejection."

A, C, D

A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. There is a nontender axillary lump. c. The patient's skin is thin and fragile. d. The patient's blood pressure is 150/92

B

A nurse is caring for a client who has had a liver transplant. Mycophenolate mofetil (CellCept) was prescribed. Which of the following will be included in the discharge instruction for this client? A. Aspirin or ibuprofen may be used for pain B. Pregnancy is allowed C. Cholesterol level will rise D. client may shop and socialize with groups

C

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client's voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning

C

A nurse is providing discharge teaching to a client who has undergone a kidney transplant. For which of the following signs or symptoms should the nurse advise the client to monitor for rejection of the transplant? A. Low serum creatinine and creatinine clearance B. Anorexia and weight loss C. Decreased urinary output and high BP D. Nausea and vomiting

C

A nurse is teaching a client who is postoperative following a kidney transplant and is taking cyclosporine. Which of the following instructions should the nurse include? A. "Decrease your intake of protein‑rich foods." B. "Take this medication with grapefruit juice." C. "Monitor for and report a sore throat to your provider." D. "Expect your skin to turn yellow

C

How does the nurse recognize that the client is in early stages of septic shock? A. Pallor and cool skin B. Blood pressure 84/50 C. Tachypnea & tachycardia D. Respiratory acidosis

C

A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "I will choose a diet high in fat to help gain weight." B. "I will be sure to eat three large meals daily." C. "I will drink up to 1 liter of liquid each day." D. "I will add high‑protein foods to my diet.

D

The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

D

Which of the following indicate early sepsis, which has an excellent recovery rate if treated promptly? A. Localized erythema and edema B. Low-grade fever & low white blood cell count C. Low oxygen saturation & decreased cognition D. Reduced urinary output & increased respiratory rate

D

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client? A. Current range of motion in all extremities B. Heart rate and rhythm C. Respiratory rate and pulse oximetry reading D. Orientation to time, place, and person

B Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. It is also important to obtain the patient's cardiac history, including any history of prior arrhythmias.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral feedings. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day.

B Enteral feedings can usually be started during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients unless the gastrointestinal tract is not available for use.

Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? A. 75-year-old man with hypertension and early Alzheimer's disease B. 68-year-old woman 2 days postoperative from bowel surgery C. 80-year-old community-dwelling man with no other health problems undergoing cataract surgery D. 54-year-old woman with moderate asthma and severe degenerative joint disease of the right knee

B The 68-year-old woman has several risk factors. First she is an older adult, and immune function decreases with age. The greatest risk factor is that she has just had bowel surgery. Not only does major surgery further reduce the immune response, the bowel cannot be "sterilized" for surgery. Therefore the usual bacteria of the bowel have the chance to escape the site and enter the bloodstream when the bowel is disrupted.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.

B The decrease in pulse and numbness in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased, and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

B The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function? a. Monitor white blood cells (WBCs). b. Continue to measure the urine output. c. Assess that blisters and edema have subsided. d. Encourage the patient to eat an adequate number of calories.

B The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. WBCs may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. Although adequate nutrition is important for healing, it does not ensure adequate kidney functioning.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

B With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

After teaching a patient on immunosuppressant therapy after a kidney transplant about the posttransplant drug regimen, the nurse determines that additional teaching is needed when the patient says, a. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." b. "I need to be monitored closely because I have a greater chance of developing malignant tumors." c. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor." d. "The drugs are given in combination because they inhibit different aspects of transplant rejection."

C

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

C All patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered 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 should the nurse infuse the IV fluids? a. 219 mL/hr b. 625 mL/hr c. 938 mL/hr d. 1875 mL/hr

C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours.

A 23-year-old male client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? A. How to maintain home smoke detectors B. Joining a community reintegration program C. Learning to perform dressing changes D. Options available for scar removal

C Proper management of burn injury through proper dressing changes helps prevent wound deterioration. Encouragement of the patient and his family members in participating in dressing changes and wound care helps prepare for the patient's eventual discharge and home care needs. All other choices (below) are important during the rehabilitation stage but dressing changes is a priority.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours. b. Continuing to monitor the laboratory results. c. Increasing the rate of the ordered IV solution. d. Typing and crossmatching for a blood transfusion.

C The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every1 hour).

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation.

D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.