NRSG 3420: EXAM 3

ER MCI DISASTER

ER MCI DISASTER

RENAL

RENAL

SHOCK MODS BURNS

SHOCK MODS BURNS

The nurse is planning client teaching for a client with end-stage kidney disease who is scheduled for the creation of a fistula. The nurse should teach the client what information about the fistula? "A vein and an artery in your arm will be attached surgically." "The arm should be immobilized for 4 to 6 days." "The fistula can be used 5 to 7 days after the surgery for dialysis treatment." "One needle will be inserted into the fistula for each dialysis treatment."

Correct response: "A vein and an artery in your arm will be attached surgically." Explanation: The fistula joins an artery and a vein, either side-to-side or end-to-end. This access will need several weeks to "mature" before it can be used. The client is encouraged to perform exercises to increase the size of the affected vessels (e.g., squeezing a rubber ball for forearm fistulas). Two needles will be inserted into the fistula for each dialysis treatment. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 54: Management of Patients With Kidney Disorders, Arteriovenous Fistula, p. 1591.

The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup." "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. " "It is normal to be a little confused following surgery, and it is safe not to urinate at night."

Correct response: "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." Explanation: In elderly clients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Gerontologic Considerations, p. 260.

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as 18%. 9%. 27%. 36%.

Correct response: 18%. Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the total body surface area (TBSA), quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). In this case the client's abdomen (9%) and front of the left leg (9%) add up to 18%. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1848.

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? Increased urine output Hyperactive bowel sounds Cool, clammy skin Decreased heart rate

Correct response: Cool, clammy skin Explanation: 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 client'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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Table 14-1, p. 299.

The nurse coming on shift on the medical unit is taking a report on four clients. What client does the nurse know is at the greatest risk of developing ESKD? A client with a history of polycystic kidney disease A client who is morbidly obese with a history of vascular disorders A client with severe chronic obstructive pulmonary disease A client with diabetes mellitus and poorly controlled hypertension

Correct response: A client with diabetes mellitus and poorly controlled hypertension Explanation: Systemic diseases, such as diabetes mellitus (leading cause); hypertension; chronic glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary lesions, such as in polycystic kidney disease; vascular disorders; infections; medications; or toxic agents may cause ESKD. A client with more than one of these risk factors is at the greatest risk for developing ESKD. Therefore, the client with diabetes and hypertension is likely at highest risk for ESKD. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 54: Management of Patients With Kidney Disorders, Chronic Kidney Disease, p. 1569.

A homeless person is admitted the ED during a blizzard, and is unable to feel his feet and lower legs. Core temperature is noted at 33.2°C (91.8ºF). The client is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this client? Addressing the client's frostbite in his lower extremities Addressing the client's hypothermia Addressing the client's malnutrition Addressing the client's alcohol intoxication

Correct response: Addressing the client's hypothermia Explanation: The client may also have frostbite, but hypothermia takes precedence in treatment because it is systemic rather than localized. The alcohol abuse and the alteration in nutrition do not take precedence over the treatment of hypothermia because both problems are a less acute threat to the client's survival. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Hypothermia, p. 2173.

A client is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the client's cardiopulmonary status, the nurse should prepare to perform what intervention? Administer naloxone hydrochloride (Narcan). Insert an indwelling urinary catheter. Perform a focused neurologic assessment. Administer a bolus of lactated Ringer's.

Correct response: Administer naloxone hydrochloride (Narcan). Explanation: Naloxone is an opioid antagonist that is given for the treatment of narcotic overdoses. There is no definitive need for a urinary catheter or for a bolus of lactated Ringer's. The client's basic neurologic status should be ascertained during the rapid assessment, but a detailed examination is less important than administration of an antidote. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Table 72-1, p. 2181.

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? Fluid balance Anxiety and fear Pain Airway management

Correct response: Airway management Explanation: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Pulmonary Alterations, p. 1852.

Level C personal protective equipment has been deemed necessary in the response to an unknown substance. The nurse is aware that the equipment will include what? A vapor-tight, chemical-resistant suit A uniform only An air-purified respirator A self-contained breathing apparatus

Correct response: An air-purified respirator Explanation: Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical-resistant gloves, and boots. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection, incorporating a vapor-tight, chemical-resistant suit and self-contained breathing apparatus (SCBA). Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection, incorporating a chemical-resistant suit and SCBA. Level D is the same as a work uniform. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Personal Protective Equipment, p. 2201.

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. Neurogenic Cardiogenic Hypovolemic Anaphylactic Septic

Correct response: Anaphylactic Septic Neurogenic Explanation: The varied mechanisms leading to the initial vasodilation in distributive shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of distributive shock. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Distributive Shock, p. 313.

The nurse is admitting a client who is suspected of having heat stroke. What assessment finding would be most consistent with this diagnosis? Anhidrosis Cheyne-Stokes respirations Copious diuresis Hypertension with a wide pulse pressure

Correct response: Anhidrosis Explanation: Heat stroke is manifested by anhidrosis confusion, bizarre behavior, coma, elevated body temperature, hot dry skin, tachypnea, hypotension, and tachycardia. This health problem is not associated with anhidrosis or Cheyne-Stokes respirations. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Assessment and Diagnostic Findings, p. 2172.

An adult client has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this patient. What aspect of his care should be prioritized by the home health nurse? Providing supervision to home health aides in providing necessary client care Providing ongoing medical care during the family's rehabilitation phase Assisting the client and family to identify and mobilize community resources Reinforcing the importance of continuous assessment with the family

Correct response: Assisting the client and family to identify and mobilize community resources Explanation: The home care nurse reinforces the importance of continuing medical care and helps the client and family identify and mobilize community resources. The home health nurse is part of a team that provides client care in the home. The nurse does not directly supervise home health aides. The nurse provides nursing care to both the client and family, not just the family. The nurse performs continuous and ongoing assessment of the client; he or she does not just reinforce the importance of that assessment. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Continuing and Transitional Care, p. 320.

A workplace explosion has left a 40-year-old man with full thickness burns over 75% of his body. Despite his injuries, the man is conscious. How would this person be triaged? Yellow Red Black Green

Correct response: Black Explanation: The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. The client would be triaged as black due to the unlikelihood of survival. Persons triaged as green, yellow, or red have a higher chance of recovery. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Table 73-1, p. 2197.

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

Correct response: Cells lack an adequate blood supply and are deprived of oxygen and nutrients. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Overview of Shock, p. 296.

A client 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? Check the client's blood glucose level. Determine whether the client has ingested a corrosive substance. Arrange for assessment of serum potassium levels. Assess for a documented history of major depression.

Correct response: Check the client's blood glucose level. Explanation: Hypoglycemia can mimic alcohol intoxication and should be assessed in a client suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Acute Alcohol Intoxication, p. 2185.

A client is brought to the ER in an unconscious state. The health care provider notes that the client is in need of emergency surgery. No family members are present, and the client does not have identification. What action by the nurse is most important regarding consent for treatment? Clearly document LOC and health status on the client's chart. Obtain a court order to treat the client. Ask the social worker to come and sign the consent. Contact the police to obtain the client's identity.

Correct response: Clearly document LOC and health status on the client's chart. Explanation: When clients are unconscious and in critical condition, the condition and situation should be documented to administer treatment quickly and timely when no consent can be obtained by usual routes. A social worker is not asked to sign the consent. Finding the client's identity is not a priority. Obtaining a court order would take too long. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Documentation of Consent and Privacy, p. 2157.

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the client's peritoneum, the nurse should anticipate what diagnostic test? Radiograph Barium swallow Computed tomography (CT) scan Complete blood count (CBC)

Correct response: Computed tomography (CT) scan Explanation: CT scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield sufficient data and a CBC would not reveal the presence of intraperitoneal injury. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Intraperitoneal Injury, p. 2170.

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

Correct response: Continuously Explanation: Elastic pressure garments are worn continuously (i.e., 24 hours a day). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Prevention and Treatment of Scars, p. 1869.

A geriatric nurse is performing an assessment of body systems on an 85-year-old client. The nurse should be aware of what age-related change affecting the renal or urinary system? Urinary incontinence Increased bladder capacity Increased ability to concentrate urine Decreased glomerular filtration rate

Correct response: Decreased glomerular filtration rate Explanation: Many age-related changes in the renal and urinary systems should be taken into consideration when taking a health history of the older adult. One change includes a decreased glomerular surface area resulting in a decreased glomerular filtration rate. Other changes include the decreased ability to concentrate urine and a decreased bladder capacity. It also should be understood that urinary incontinence is not a normal age-related change, but is common in older adults, especially in women because of the loss of pelvic muscle tone. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 53: Assessment of Kidney and Urinary Function, Gerontologic Considerations, p. 1554.

A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse is working with the client to adapt the client's diet to maximize the therapeutic effect and minimize the risks of complications. The client's diet should include which of the following modifications? Select all that apply. Decreased protein intake Vitamin D supplementation Increased potassium intake Decreased sodium intake Fluid restriction

Correct response: Decreased protein intake Decreased sodium intake Fluid restriction Explanation: Restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months. Restriction of fluid is also part of the dietary prescription because fluid accumulation may occur. As well, sodium is usually restricted to 2 to 3 g/day. Potassium intake is usually limited, not increased, and there is no particular need for vitamin D supplementation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 54: Management of Patients With Kidney Disorders, Promoting Nutritional and Fluid Therapy, p. 1592.

The nurse is assessing a client admitted with renal stones. During the admission assessment, what parameters should the nurse address? Select all that apply. Surgical history Vaccination history Family history of renal stones Dietary history Medication history

Correct response: Dietary history Family history of renal stones Medication history Explanation: Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the client to stone formation. When caring for a client with renal stones it would not normally be a priority to assess the vaccination history or surgical history, since these factors are not usually related to the etiology of kidney stones. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Assessment and Diagnostic Findings, p. 1633.

A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply. Cardiovascular overload Hypoglycemia Difficulty breathing Hypovolemia Pulmonary edema

Correct response: Difficulty breathing Cardiovascular overload Pulmonary edema Explanation: Fluid replacement complications can occur, often when large volumes are given rapidly. Therefore, the nurse monitors the client closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Administering Blood and Fluids Safely, p. 309.

The nurse in the ED is caring for a client recently admitted with a likely myocardial infarction. The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess? Increase in heart rate Increase in blood pressure Decrease in oxygen demands Dysrhythmias

Correct response: Dysrhythmias Explanation: Cardiogenic shock occurs when the heart's ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. Symptoms of cardiogenic shock include angina pain and dysrhythmias. Cardiogenic shock does not cause increased blood pressure, increased heart rate, or a decrease in oxygen demands. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Clinical Manifestations, p. 310.

The nurse is caring for a client with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a client with an indwelling catheter? Vigorously clean the meatus area daily. Empty the drainage bag at least every 8 hours. Irrigate the catheter every 8 hours with normal saline. Apply powder to the perineal area twice daily.

Correct response: Empty the drainage bag at least every 8 hours. Explanation: To reduce the risk of bacterial proliferation, the nurse should empty the collection bag at least every 8 hours through the drainage spout, and more frequently if there is a large volume of urine. Vigorous cleaning of the meatus while the catheter is in place is discouraged, because the cleaning action can move the catheter, increasing the risk of infection. The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Irrigation of the catheter opens the closed system, increasing the likelihood of infection. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Chart 55-10, p. 1630.

The nurse has been notified that the ED is expecting terrorist attack victims and that level D personal protective equipment (PPE) is appropriate. What does level D PPE include? A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots A self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical-resistant suit with chemical-resistant gloves and boots. The SCBA and a chemical-resistant suit, but the suit is not vapor tight The nurse's typical work uniform

Correct response: The nurse's typical work uniform Explanation: The typical work uniform is appropriate for Level D protection Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Personal Protective Equipment, p. 2201.

An adult client has been hospitalized with pyelonephritis. The nurse's review of the client's intake and output records reveals that the client has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding? Obtain an order for a high-sodium diet to prevent dilutional hyponatremia. Supplement the client's fluid intake with a high-calorie diet. Encourage the client to continue this pattern of fluid intake. Emphasize the need to limit intake to 2 L of fluid daily.

Correct response: Encourage the client to continue this pattern of fluid intake. Explanation: Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. Consequently, there is no need to supplement this fluid intake with additional calories or sodium. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Nursing Management, p. 1622.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? Ensure the client has sufficient potassium intake. Maintain a low sodium diet. Encourage the use of over-the-counter calcium supplements. Encourage fluid intake.

Correct response: Ensure the client has sufficient potassium intake. Explanation: Diuretics cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake and increased fluid intake does not reduce the client's risk for electrolyte disturbances. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Pharmacologic Therap, p. 263.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? Risk of infection Psychosocial coping Nutritional status Fluid status

Correct response: Fluid status Explanation: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Cardiovascular Alterations, p. 1851.

The nurse is caring for a client in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What assessments and interventions should the nurse prioritize? Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions Reviewing medications, performing a focused cardiovascular assessment, and providing client education Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema

Correct response: Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration Explanation: When vasoactive medications are given, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be given through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. Individual medication dosages are usually titrated by the nurse, who adjusts drip rates based on the prescribed dose and the client's response. Reviewing medications, performing a focused cardiovascular assessment, and providing client education are important nursing tasks, but they are not specific to the administration of IV vasoactive drugs. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Vasoactive Medication Therapy, p. 306.

A client is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm? Full partial thickness Deep partial thickness Superficial partial thickness Full thickness

Correct response: Full thickness Explanation: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the client will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the client will complain of pain and sensitivity to cold air. Full partial thickness is not a depth of burn. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847.

A nurse is participating in the planning of a hospital's emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions? Having an ethical framework in place prior to an emergency Teaching staff that principles of ethics do not apply in an emergency situation Allowing staff to provide care anonymously during an emergency Assuring staff that they are not legally accountable for care provided during an emergency

Correct response: Having an ethical framework in place prior to an emergency Explanation: Nurses can plan for the ethical dilemmas they may face during disasters by establishing a framework for evaluating ethical questions before they arise and by identifying and exploring possible responses to difficult clinical situations. Ethical principles do not become wholly irrelevant in emergencies. Care cannot be given anonymously and accountability for practice always exists, even in an emergency. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Considering Ethical Conflicts, p. 2198.

The ICU nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring? Urinary output increases Heart and respiratory rates are elevated Adventitious lung sounds occur in the upper airway Skin becomes warm and dry

Correct response: Heart and respiratory rates are elevated Explanation: As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the client begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., acute kidney injury, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Pathophysiology, p. 315.

One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve what goal? Help evaluate pituitary gland function Help distinguish reduced renal blood flow from decreased renal function Help provide an effective treatment for hypertension-induced oliguria Help distinguish hyponatremia from hypernatremia

Correct response: Help distinguish reduced renal blood flow from decreased renal function Explanation: If a client is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a client with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Medical Management, p. 260.

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what? Hyperkalemia, hyponatremia, elevated hematocrit Hyperkalemia, hypernatremia, decreased hematocrit Hypokalemia, hyponatremia, elevated hematocrit Hypokalemia, hypernatremia, decreased hematocrit

Correct response: Hyperkalemia, hyponatremia, elevated hematocrit Explanation: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Fluid and Electrolyte Alterations, p. 1851.

There has been a radiation-based terrorist attack and a client is experiencing vomiting, diarrhea, and shock after the attack. How will the client's likelihood of survival be characterized? Extended Improbable Possible Probable

Correct response: Improbable Explanation: Clients who experience vomiting, diarrhea, and shock after radiation exposure are categorized as improbable survival, because they are demonstrating symptoms of exposure levels of more than 800 rads of total body-penetrating irradiation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Survival, p. 2211.

The nurse is caring for a client who has been diagnosed with renal calculi. Prompt management of renal calculi is most important when the stone is located where? In the ureteropelvic junction In the ureterovesical junction In the urethra In the ureteral segment near the sacroiliac junction

Correct response: In the ureteropelvic junction Explanation: The three narrowed areas of each ureter are the ureteropelvic junction, the ureteral segment near the sacroiliac junction, and the ureterovesical junction. These three areas of the ureters have a propensity for obstruction by renal calculi or stricture. Obstruction of the ureteropelvic junction is most serious because of its close proximity to the kidney and the risk of associated kidney dysfunction. The urethra is not part of the ureter. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 53: Assessment of Kidney and Urinary Function, Ureters, Bladder, and Urethra, p. 1550.

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? Perform mechanical débridement to remove the exudate and prevent further infection. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. Inform the primary care provider promptly because the graft may need to be removed. Document this finding as an expected phase of graft healing.

Correct response: Inform the primary care provider promptly because the graft may need to be removed. Explanation: An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem and the nurse would not independently perform débridement. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Homografts and Xenografts, p. 1864.

The nurse and urologist have both been unsuccessful in catheterizing a client with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the health care provider to use to drain the client's bladder? Scheduling the client immediately for a prostatectomy Medication administration to relax the bladder muscles and reattempting catheterization in 6 hours Application of warm compresses to the perineum to assist with relaxation Insertion of a suprapubic catheter

Correct response: Insertion of a suprapubic catheter Explanation: When the client cannot void, catheterization is used to prevent overdistention of the bladder. In the case of prostatic obstruction, attempts at catheterization by the urologist may not be successful, requiring insertion of a suprapubic catheter. A prostatectomy may be necessary, but would not be undertaken for the sole purpose of relieving a urethral obstruction. Delaying by applying compresses or administering medications could result in harm. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Promoting Urinary Elimination, p. 1627.

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? 3% NaCl Dextran Lactated Ringer's Albumin

Correct response: Lactated Ringer's Explanation: Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer's 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Crystalloid and Colloid Solutions, p. 304.

A nurse is caring for clients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered? Level A Level D Level B Level C

Correct response: Level B Explanation: Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection. Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical resistant gloves, and boots. Level D is the same as a work uniform. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Personal Protective Equipment, p. 2201.

A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound? Silver sulfadiazine 1% (Silvadene) water-soluble cream Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream Silver nitrate 0.5% aqueous solution Acticoat

Correct response: Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream Explanation: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a type of silver dressing. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-4, p. 1862.

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury? Minor; treatment can be delayed hours to days Extensive; chances of survival are unlikely even with definitive care Life-threatening but survivable with minimal intervention Significant; injuries require medical care but can wait hours without threat to life or limb

Correct response: Minor; treatment can be delayed hours to days Explanation: A green triage tag (priority 3, or minimal) indicates injuries that are minor; treatment can be delayed hours to days. A red triage tag (priority 1, or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2, or delayed) indicates injuries that are significant and require medical care but can wait hours without threat to life or limb. A black triage tag (priority 4, or expectant) indicates injuries that are extensive; chances of survival are unlikely even with definitive care. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Table 73-1, p. 2197.

A nurse in the ICU receives report from the nurse in the ED about a new client 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 client is probably experiencing? Neurogenic shock Anaphylactic shock Septic shock Hypovolemic shock

Correct response: Neurogenic shock Explanation: Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Neurogenic Shock, p. 318.

The nurse is caring for a client who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the client? Report the presence of fine, sand like particles through the nephrostomy tube. Limit oral fluid intake for 1 to 2 days. Report any pink-tinged urine within 24 hours after the procedure. Notify the health care provider about cloudy or foul-smelling urine.

Correct response: Notify the health care provider about cloudy or foul-smelling urine. Explanation: The client should report the presence of foul-smelling or cloudy urine since this is suggestive of a UTI. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand like debris is normal due to residual stone products. Hematuria is common after lithotripsy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Educating Patients About Self-Care, p. 1646.

A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? Diffusion Hydrostatic pressure Active transport Osmosis and osmolality

Correct response: Osmosis and osmolality Explanation: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Osmosis and Osmolality, p. 253.

A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? Practice outside of her normal area of clinical expertise. Prioritize psychosocial needs over physiologic needs. Prioritize the interests of older adults over younger clients. Perform interventions that are not based on assessment data.

Correct response: Practice outside of her normal area of clinical expertise. Explanation: During a disaster, nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, The Nurse's Role in Disaster Response Plans, p. 2198.

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention? Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea Promoting communication with the client and family along with addressing end-of-life issues Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months

Correct response: Promoting communication with the client and family along with addressing end-of-life issues Explanation: Promoting communication with the client and family is a critical role of the nurse with a client in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the client's wishes. Many cases of MODS result in death and the life expectancy of clients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the client. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Nursing Management, p. 320.

The nurse, a member of the health care team in the ED, is caring for a client who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? Protect the client's airway, optimize intravascular volume, and initiate the early rehabilitation process. Inform the client's family immediately that the client will likely not survive to allow the family time to make plans and move forward. Closely monitor fluid replacement therapy, and inform the family that the client will probably survive and return to normal life. Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock.

Correct response: Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock. Explanation: The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the client does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the client and helping them to understand the irreversible stage of shock is the best intervention. Informing the client's family early that the client will likely not survive does allow the family to make plans and move forward, but informing the family too early will rob the family of hope and interrupt the grieving process. The chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of-life issues. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Irreversible Stage, p. 303.

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? Providing education to the client and family Monitoring fluid and electrolyte imbalances Treating infection Promoting thermoregulation

Correct response: Providing education to the client and family Explanation: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Supporting Patient and Family Processes, p. 1867.

A client with recurrent urinary tract infections has just undergone a cystoscopy and reports slight hematuria during the first void after the procedure. What is the nurse's most appropriate action? Promptly inform the health care provider of this assessment finding. Position the client supine and insert a Foley catheter, as prescribed. Reassure the client that this is not unexpected and then monitor the client for further bleeding. Administer a STAT dose of vitamin K, as prescribed.

Correct response: Reassure the client that this is not unexpected and then monitor the client for further bleeding. Explanation: Some burning on voiding, blood-tinged urine, and urinary frequency from trauma to the mucous membranes can be expected after cystoscopy. The nurse should explain this to the client and ensure that the bleeding resolves. No clear need exists to report this finding and it does not warrant insertion of a Foley catheter or vitamin K administration. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 53: Assessment of Kidney and Urinary Function, Nursing Interventions, p. 1565.

The nurse manager in the ED receives information that a local chemical plant has had a chemical leak. This disaster is assigned a status of level II. What should this classification indicate to the nurse? Regional efforts and aid from surrounding communities can manage the situation. The area must be evacuated immediately. Statewide or federal assistance is required. First responders can manage the situation.

Correct response: Regional efforts and aid from surrounding communities can manage the situation. Explanation: Level II disasters indicate that regional efforts and aid from the surrounding communities will be able to manage the situation. Local efforts are likely to be overwhelmed, while state and federal assistance are not likely necessary. The disaster level does not indicate the necessity of evacuation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Chart 73-2, p. 2194.

The nurse is preparing the client for mechanical débridement and informs the client that this will involve which of the following procedures? Early closure of the wound Removal of eschar until the point of pain and bleeding occurs A spontaneous separation of dead tissue from the viable tissue Shaving of burned skin layers until bleeding, viable tissue is revealed

Correct response: Removal of eschar until the point of pain and bleeding occurs Explanation: Mechanical débridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical débridement can also be accomplished through the use of topical enzymatic débridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural débridement. Shaving the burned skin layers and early wound closure are examples of surgical débridement. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Mechanical Débridement, p. 1862.

The paramedics bring a client who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim? Place items for evidence in plastic bags. Bathe the client before the examination. Respect the client's privacy during assessment. Shave all pubic hair for laboratory analysis.

Correct response: Respect the client's privacy during assessment. Explanation: The client's privacy and sensitivity must be respected, because the client will be experiencing a stress response to the assault. Pubic hair is combed or trimmed for sampling. Paper bags are used for evidence collection because plastic bags retain moisture, which promotes mold and mildew that can destroy evidence. Bathing the client before the examination would destroy or remove key evidence. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Management, p. 2188.

The nurse on a urology unit is working with a client who has been diagnosed with oxalate renal calculi. When planning this client's health education, what nutritional guidelines should the nurse provide? Encourage intake of food containing oxalates. Restrict protein intake as prescribed. Increase intake of potassium-rich foods. Follow a low-calcium diet.

Correct response: Restrict protein intake as prescribed. Explanation: Protein is restricted to 60 g/day, while sodium is restricted to 3 to 4 g/day. Low-calcium diets are generally not recommended except for true absorptive hypercalciuria. The client should avoid intake of oxalate-containing foods and there is no need to increase potassium intake. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Chart 55-12, p. 1633.

A client with kidney injury secondary to diabetic nephropathy has been admitted to the medical unit. What is the most life-threatening effect of kidney injury for which the nurse should monitor the client? Retention of potassium Lack of BP control Depletion of calcium Accumulation of wastes

Correct response: Retention of potassium Explanation: Retention of potassium is the most life-threatening effect of kidney injury. Aldosterone causes the kidney to excrete potassium, in contrast to aldosterone's effects on sodium described previously. Acid-base balance, the amount of dietary potassium intake, and the flow rate of the filtrate in the distal tubule also influence the amount of potassium secreted into the urine. Hypocalcemia, the accumulation of wastes, and lack of BP control are complications associated with kidney injury, but do not have same level of threat to the client's well-being as hyperkalemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 53: Assessment of Kidney and Urinary Function, Regulation of Electrolyte Excretion, p. 1552.

A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the client's postprocedure care? Insert a urinary catheter for 24 to 48 hours after the procedure. Strain the client's urine following the procedure. Monitor the client for fluid overload following the procedure. Administer a bolus of 500 mL normal saline following the procedure.

Correct response: Strain the client's urine following the procedure. Explanation: Following ESWL, the nurse should strain the client's urine for gravel or sand. There is no need to administer an IV bolus after the procedure and there is not a heightened risk of fluid overload. Catheter insertion is not normally indicated following ESWL. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Interventional Procedures, p. 1634.

The nurse is caring for an older adult client who has been involved in a motor vehicle accident. The client's labs indicate minimally elevated serum creatinine levels. The nurse should assess for signs of what change? Acute kidney injury Decreased cardiac output Substantially reduced renal function Alterations in ratio of body fluids to muscle mass

Correct response: Substantially reduced renal function Explanation: Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acid-base disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production. Therefore, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in older adults. Acute kidney injury is likely to cause a more significant increase in serum creatinine. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Gerontologic Considerations, p. 258.

The nurse is caring for acutely ill client. What assessment finding should prompt the nurse to inform the physician that the client may be exhibiting signs of acute kidney injury (AKI)? The client complains of acute flank pain. The client's urine is cloudy with a foul odor. The client's average urine output has been 10 mL/hr for several hours. The client reports an inability to initiate voiding.

Correct response: The client's average urine output has been 10 mL/hr for several hours. Explanation: Oliguria (<500 mL/day of urine) is the most common clinical situation seen in AKI. Flank pain and inability to initiate voiding are not characteristic of AKI. Cloudy, foul-smelling urine is suggestive of a urinary tract infection. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 54: Management of Patients With Kidney Disorders, Phases of Acute Kidney Injury, p. 1577.

The nurse is assessing a client's bladder by percussion. The nurse elicits dullness after the client has voided. How should the nurse interpret this assessment finding? The client has kidney enlargement. The client's bladder is not completely empty. The client has a fluid volume deficit. The client has a ureteral obstruction.

Correct response: The client's bladder is not completely empty. Explanation: Dullness to percussion of the bladder following voiding indicates incomplete bladder emptying. Enlargement of the kidneys can be attributed to numerous conditions such as polycystic kidney disease or hydronephrosis and is not related to bladder fullness. Dehydration and ureteral obstruction are not related to bladder fullness; in fact, these conditions result in decreased flow of urine to the bladder. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 53: Assessment of Kidney and Urinary Function, Physical Assessment, p. 1558.

A client on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurse's care of this client? The client is likely to respond favorably to lithotripsy treatment of the cysts. The client's disease is incurable and the nurse's interventions will be supportive. The disease is self-limiting and cysts usually resolve spontaneously in the fifth or sixth decade of life. The client will eventually require surgical removal of his or her renal cysts.

Correct response: The client's disease is incurable and the nurse's interventions will be supportive. Explanation: PKD is incurable and care focuses on support and symptom control. It is not self-limiting and is not treated surgically or with lithotripsy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 54: Management of Patients With Kidney Disorders, Medical Management, p. 1574.

A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states, "A client with kidney disease partially loses the ability to regulate changes in pH." What is the cause of this partial inability? The kidneys combine carbonic acid and bicarbonate to maintain a stable pH. The kidneys buffer acids through electrolyte changes. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. The kidneys regulate and reabsorb carbonic acid to change and maintain pH.

Correct response: The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. Explanation: The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Acid-Base Disturbances, p. 283.

The nurse is teaching a health class about UTIs to a group of older adults. What characteristic of UTIs should the nurse cite? Men over age 65 are equally prone to UTIs as women, but are more often asymptomatic. The prevalence of UTIs in older men approaches that of women in the same age group. Men of all ages are less prone to UTIs, but typically experience more severe symptoms. The prevalence of UTIs in men cannot be reliably measured, as men generally do not report UTIs.

Correct response: The prevalence of UTIs in older men approaches that of women in the same age group. Explanation: The antibacterial activity of the prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging, resulting in increased incidence. Men are not more likely to be asymptomatic and are not known to be reluctant to report UTIs. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Gerontologic Considerations, p. 1617.

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? The source of the burn The length of time since the burn The location of burned skin surfaces The total body surface area (TBSA) affected by the burn

Correct response: The total body surface area (TBSA) affected by the burn Explanation: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Incidence, p. 1846.

The nurse is preparing to admit clients who have been the victim of a blast injury. The nurse should expect to treat a large number of clients who have experienced what type of injury? Meningeal tears Tympanic membrane rupture Chemical burns Spinal cord injury

Correct response: Tympanic membrane rupture Explanation: Tympanic membrane (TM) rupture is the most frequent injury after subjection to a pressure wave resulting from a blast injury because the TM is the body's most sensitive organ to pressure. In most cases, other injuries such as meningeal tears, spinal cord injury, and chemical injuries are likely to be less common. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Tympanic Membrane Rupture, p. 2203.

The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply. Participates actively in daily activities Covers face with a scarf Reports absence of sleep disturbance Wears hats and wigs

Correct response: Wears hats and wigs Participates actively in daily activities Explanation: The following are indicators that a client is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the client is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured client but is not related to body image disturbance. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1872.

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? escharotomy debridement silvadene application allograft

Correct response: escharotomy Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1851.

A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure? hemoconcentration histamine fluid, electrolyte status anemia

Correct response: hemoconcentration Explanation: The client with a burn experiences hemoconcentration when the plasma component of blood is lost or trapped. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1852.

Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the: maxillofacial injury and gurgling respirations. lumbar spinal cord injury and lower extremity paralysis. second-trimester pregnancy in premature labor. severe head injury and no blood pressure.

Correct response: maxillofacial injury and gurgling respirations. Explanation: Emergency department triage involves giving priority to clients at highest risk for loss of life, limb, or vision. Clients with poor prognoses are given a lesser priority. The client with the maxillofacial injury and gurgling respirations needs immediate attention because of an impaired airway. The spinal cord injury client doesn't exhibit immediate airway needs. The client with the severe head injury and no blood pressure has a grave prognosis. Although the client in early labor is an urgent priority, early labor doesn't surpass airway compromise in importance. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Triage, p. 2197.