Questions for Adult Health 2 exam #2

•Using the Parkland formula, an 85-kg patient with a 35% total body surface area (TBSA) burn is to receive a total of 5950 mL of fluid resuscitation within the first 24 hours after injury. How much of this total volume will the patient receive in the first 8 hours of fluid resuscitation?

2975 mL According to the Parkland formula, half of the calculated amount of fluid is administered to the patient in the first 8 hours after injury, 25% is given in the second 8 hours, and 25% is given in the third 8 hours

3. Estimate the total body surface area burn injury using the rule of 9's. Burns involve the entire right arm and upper back. _____%

18%

4. An older woman arrives in the ED reporting severe pain in her right shoulder. The nurse notes her clothes are soiled with urine and feces. She tells the nurse that she lives with her son and that she "fell." She is tearful and asks you if she can be admitted. What possibility should the nurse consider? a. Dementia b. Possible cancer c. Family violence d. Orthostatic hypotension

c

The nurse monitors the patient with positive pressure mechanical ventilation for a. paralytic ileus because pressure on the abdominal contents affects bowel motility. b. diuresis and sodium depletion because of increased release of atrial natriuretic peptide. c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return. d. respiratory acidosis in a patient with COPD because of alveolar hyperventilation

c

4. A patient is hospitalized with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. The respiratory therapist applied a non-rebreather mask. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Respiratory rate is 6/min. Oxygen saturation decreases to 88%. The patient is unresponsive. What is the priority nursing intervention? a. Notify the HCP and get ready for intubation. b. Encourage the patient to cough and auscultate the lungs again. c. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. d. Document the findings and continue to monitor the patient's breathing.

A

5. Which lab result supports the need for additional IV fluid to treat burn shock? a. Hematocrit 52% b. Sodium 137 mEq/L c. WBC 12.5 × 109/L d. Potassium 3.4 mmol/L

A

6. What nutrition intervention may promote wound healing for a patient with a 10% burn injury? a. Eat a high-protein, high-carbohydrate diet b. Increase normal caloric intake by about 4 times c. Eat at least 1500 calories/day in small, frequent meals d. Eat a lactose-free diet to reduce the potential for diarrhea

A

9. What intervention prevents hypertrophic scarring during the rehabilitation phase of burn recovery? a. Applying pressure garments b. Repositioning the patient every 2 hours c. Performing active ROM at least every 4 hours d. Applying a water-based moisturizer to healed skin

A

The ventilator settings for a patient on a volume ventilator include a synchronized intermittent mandatory ventilation (SIMV) mode with 5 cm H2O PEEP. After 3 hours of ventilation, the patient's PaO2 has dropped from 82 mm Hg to 74 mm Hg. The most accurate interpretation of this finding by the nurse is that the: A. patient's respiratory rate may be decreasing, lowering the oxygen content of the blood. B. ventilator is creating high intrathoracic pressure, suppressing venous return and cardiac output. C. tidal volume provided by the ventilator is too high, increasing the amount of CO2 being exhaled. D. pressure applied by PEEP requires an increased fraction of inspired oxygen (FIO2) to maintain oxygenation.

A Rationale: Disadvantages have been noted with synchronized intermittent mandatory ventilation (SIMV). If spontaneous breathing decreases when the preset rate is low, ventilation might not be adequately supported. Only patients with regular, spontaneous breathing should use low-rate SIMV.

Which of the following patients will NOT require oxygen (Select all that apply) a.) a pt with dyspnea but normal SpO2 b.) A pt with anemia c.) A pt who is wheezing with Sp02 level of 90 d.) A pt presenting with peripheral cyanosis with Sp02 of 97%

A, B, D because a patient presenting with normal Spo2 will not benefit from oxygen treatment since the underlying cause of distress is something else maybe an obstruction, excessive mucous production, infection or inflammation.

8. What nursing interventions can be used to manage burn pain? (select all that apply) a. Suggest pain management options. b. Use a pain-rating tool to monitor the patient's level of pain. c. Delay painful dressing changes until the patient's pain is completely relieved. d. Use a multimodal approach (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. Provide nonpharmacologic therapies (e.g., music therapy, distraction) to replace opioids in the acute phase of a burn injury.

A,B,D

3. Treatment for cardiogenic shock includes (select all that apply) a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. Trendelenburg positioning to facilitate venous return and increase preload

A,C

2. A 78-year-old man with a history of diabetes has confusion and temperature of 104°F (40°C). There is a wound on his right heel with purulent drainage. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/min; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.

B

•A patient has sustained a burn related to spilling a cup of hot liquid onto the right hand. Symptoms include skin that is bright red and mottled at the affected area with a wet and weeping appearance and diffuse blister formation. The burned area is excruciatingly painful and sensitive to air current. What is the appropriate classification for this burn? •A) Superficial B) Superficial dermal c) Deep Dermal Partial-thickness patches D) Thermal

B

During the exudative phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse you know this will lead to? A. bronchoconstriction B. atelectasis C. upper airway blockage D. pulmonary edema

B . Surfactant decreases surface tension in the lungs. Therefore, the alveoli sacs will stay stable when a person exhales (hence the sac won't collapse). If there is a decrease in surfactant production this creates an unpredictable alveoli sac that can easily collapse, hence a condition called ATELETASIS will occur (collapse of the lung tissue) when there is a decrease production in surfactant.

2. Which wound description indicates a need for excision and grafting? (select all that apply) a. Red, painful blisters b. Leathery, brown, exposed tendon c. Pearly white color, insensitive to pain, dry d. Charred eschar, visible thrombosed blood vessels e. Large, fluid-filled vesicles, moderate edema, moist, red

B,C,D

1. Which instruction would the nurse provide to prevent burn injuries? a. Set hot water temperature at 140°F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Do not allow older adults to cook unattended.

C

A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS? A. infiltrates only on the upper lobes B. enlargement of the heart with bilateral lower lobe infiltrates C. white-out infiltrates bilaterally D. normal chest x-ray

C

While performing triage in the ED, the nurse determines which patient should be seen first? a.A patient with burns on the face and chest; BP 120/80 mm Hg, HR 92, RR 24 b.A patient with a deformed leg indicating a fractured tibia; BP 110/60 mm Hg, HR 86, RR 18 c.A patient with type 1 diabetes in ketoacidosis; BP 100/60 mm Hg, HR 100 beats/min, RR 32 d.A patient with a respiratory infection with a cough productive of greenish sputum; BP 128/86 mm Hg, HR 88, RR 26

C

•A patient has sustained a traumatic, full-thickness burn injury to the chest wall. The patient now shows symptoms that include rapid, shallow respirations; poor chest excursion; agitation; and wheezing. Arterial blood gases reveal an increasing partial pressure of carbon dioxide (PaCO2). What action should the nurse anticipate next? •A Administration of anxiolytic therapy •B Administration of albuterol 2.5 mg •C Intubation and mechanical ventilation D Immediate escharotomy

C Circumferential, full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Clinical manifestations of chest wall restriction include rapid, shallow respirations; poor chest wall excursion; and severe agitation. Intubation addresses these issues.

•What parameter is used instead of the Parkland formula to assess fluid resuscitation in the patient with electrical burns? •A. Serum creatinine •B. Hematocrit/Hemoglobin •C. Urinary Output •D. Central venous pressure

C . Correct Urine output Fluid resuscitation for an electrical burn patient does not correlate with the Parkland formula, and the fluid is adjusted according to the patient's urine output. If myoglobin is present in the urine, a urine output greater than 100 mL/h in adults and 2 mL/kg/h in children is established until the urine is clear of all myoglobin pigment.

A pt presents to the ER with difficulty breathing, SOB, chest pain, fatigue and dizziness. Upon checking the vital signs the nursing student notices that the patient's SPO2 level is 96%, yet the patient complains of difficulty with breathing. What is the next thing the student will do? a.) do nothing because the patient's SpO2 is within normal range b.) apply oxygen via nasal cannula @ 2l/min c.) give the patient a bronchodilator via nebulizer d.) Apply the simple face mask

C.) Give the patient a nebulizer because the signs they present with are characteristic of asthma so giving them a bronchodilator will help open the airway a.) is incorrect - although the Spo2 is normal, there could be other things that are causing the dyspnea.b.) Applying oxygen when Spo2 is normal will not help the patient because the problem is not that they are oxygen deficient. It is that they cannot breathe properly.c.) Incorrect because the nursing student should be able to administer the medicationd.) a simple face mask will also not help them because the pt is dealing with an obstructed airway

1. A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing a. a relative hypervolemia. b. an absolute hypovolemia. c. neurogenic shock from low blood flow. d. neurogenic shock from massive vasodilation

D

10. A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care team is planning for discharge. The first action the nurse would take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. give the patient written information and websites resources for burn survivors. c. teach the patient and the caregiver proper wound care to be performed at home. d. review the patient's current health care status and readiness for discharge to home.

D

4. The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.

D

7. A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. What is the most important nursing intervention following surgery? a. Wash the wound with soap and water 3 times a day. b. Medicate for pain relief in between dressing changes. c. Reapply a new dressing without disturbing the wound bed. d. Assess the wound for signs of infection during dressing changes.

D

Assessment of a male patient during the primary survey indicates delayed capillary refill of the extremities. He cannot explain the events before admission to the ED. Which action should the nurse take immediately? a.Apply leads to the patient's chest to initiate ECG monitoring. b.Insert 2 large-bore IV catheters to start IV fluid resuscitation. c.Continue the primary survey to complete a brief neurologic examination. d.Initiate pulse oximetry by placing a monitoring device on the patient's index finger.

D

You're teaching a class on critical care concepts to a group of new nurses. You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding about this condition. Which statement by a new nurse demonstrates he understands the condition? A. "This condition develops because the exocrine glands start to work incorrectly leading to thick, copious mucous to collect in the alveoli sacs." B. "ARDS is a pulmonary disease that gradually causes chronic obstruction of airflow from the lungs." C. "Acute respiratory distress syndrome occurs due to the collapsing of a lung because air has accumulated in the pleural space." D. "This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs."

D ARDS is a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak into the alveoli sac. Option A describes cystic fibrosis, option B describes COPD, and option C describes a pneumothorax.

1. An older man arrives in triage disoriented and dyspneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to a. assess his vital signs. b. obtain a brief medical history from his wife. c. start supplemental O2 and have the provider see him. d. determine the kind of insurance he has before treating him.

a

A patient with multiple gunshot wounds returns to the ICU from surgery. Vital signs are stable. They are making no spontaneous respiratory effort. Which mode of ventilation would be most appropriate? a. Assist control (AC) b. Pressure support (PS) c. Bi-level positive airway pressure (Bi-PAP) d. Synchronized intermittent mandatory ventilation (SIMV)

a

In a spontaneously breathing patient, the nurse notes tidaling of the water level in the water-seal chamber of the chest tube drainage system. The nurse would a. continue to monitor the patient. b. check all connections for a leak in the system. c. raise the collection unit above the level of the heart. d. clamp the tubing at a distal point away from the patient.

a

Which assessment finding concerns you most in a patient with pneumonia who is receiving noninvasive ventilation (Bi-PAP)? a. New onset of confusion to time and place b. Fine crackles on auscultation of affected lobe c. Patient asks to remove the mask for oral care d. HR: 98, RR: 16 bpm, BP: 110/60, SpO2: 93%

a

Which nursing action would be the highest priority when suctioning a patient with an oral ET tube or tracheostomy? a. Hyperoxygenate with 100% FIO2 before suctioning. b. Auscultate lung sounds after suctioning is completed. c. Instill 5 mL of normal saline into the tube before suctioning. d. Give antianxiety medications 30 minutes before suctioning.

a

Which patient should be the nurse's first priority? a.) A patient whose airway is obstructed by mucous b.) A patient expressing difficulty with breathing c.) A patient whose extremities are cyanotic d.) A patient who is hyperventilating

a

Which technique would be most appropriate for a patient with mild COPD to promote airway clearance? a. Huff coughing b. Postural drainage c. Pursed lip breathing d. High-frequency chest wall oscillation

a

A patient is placed on volume-cycled ventilation. The nurse plans care for this client based on which characteristic of this method of ventilation? A. Delivers a set volume, which will help overcome the client's airway resistance changes .B. The mechanism by which the phase of the breath switches from inspiration to expiration. C. Provides a consistent tidal volume. D. Delivers a preset volume of gas to the lungs to generate high pressures.

a Rationale: Volume- cycled ventilation delivers a preset volume of gas to the lungs, making volume constant therefore, overcoming the changes in lung compliance and airway resistance.

Eric, a 50 year old patient with an artificial airway begins to experience dyspnea and visibly struggles to breathe through the trach tube. What should the nurse do first? a.) call the RT b.) adjust the trach tube c.) increase the oxygen supply d.) notify the physician

a -- because the pt is unable to maintain proper oxygenation thru an artifical airway B.)- is incorrect Adjusting the trach tube might cause discomfort to the patient and it is not within the scope of a nurse to fix a trachea tube.C.)- is incorrect because increasing the oxygen supply will not help since the problem is with breathing itself and not oxygenD.)- is incorrect as well because the RT needs to be informed first and the phsycian second

What are strategies to prevent Ventilator-associated Pneumonia? select all that apply A. Oral care every 4 hours, B. HOB elevated 30-45 degrees unless contraindicated by the patient's condition C. HOB elevated 10-15 degrees, unless contraindicated by the patient's condition D. Allow family to suction patient as needed to remove secretions

a,b

Which findings indicate the patient is ready for weaning from mechanical ventilation? (select all that apply) a. Serum hemoglobin of 15 g/dL b. Respirations of 18 breaths/min c. Patient is alert and follow commands d. Chest x-ray shows large pleural effusion e. Mean arterial pressure (MAP) of 55 mm Hg f. ABGS: pH 7.38, PaCO2 37 mm Hg, 24 mEq/L, PaO2 94

a,b,c

3. What interventions does the nurse anticipate for a patient with an aspirin overdose? (select all that apply.) a. Hemodialysis b. Corticosteroids c. Hyperbaric O2 d. Gastric lavage e. Activated charcoal

a,d,e

2. A patient has a core temperature of 90°F (32.2°C). The most appropriate rewarming technique would be a. passive rewarming with warm blankets. b. active internal rewarming using warmed IV fluids. c. passive rewarming using air-filled warming blankets. d. active external rewarming by submersing in a warm bath.

b

5. A chemical explosion occurs at a nearby industrial site. First responders report that victims are decontaminated at the scene, and about 125 workers will need medical evaluation and care. The first action of the nurse receiving this report should be to a. issue a code blue alert. b. activate the hospital's emergency response plan. c. notify the Federal Emergency Management Agency (FEMA). d. arrange for the American Red Cross to provide aid to victims.

b

After a left lower lobe lobectomy, an appropriate nursing measure is to a. position the patient prone every 2 hours. b. monitor the chest tube drainage and functioning. c. auscultate lung sounds frequently in the lower left lobe. d. administer IV fluid boluses to maintain blood pressure.

b

A patient with a history of alcohol use is admitted to the ICU with hemorrhage from esophageal varices. Admission VS are BP 84/58 mm Hg, HR 105, and RR 32 breaths/min. The nurse recognizes the onset of systemic inflammatory response syndrome (SIRS) upon finding: a.dysrhythmias. b.pulmonary edema. c.absent bowel sounds. decreasing blood pressure

b The respiratory system is often the first system to show signs of dysfunction in systemic inflammatory response syndrome. Increases in capillary permeability facilitate movement of fluid from the pulmonary vasculature into pulmonary interstitial spaces. The fluid then moves to the alveoli, causing alveolar edema and pulmonary edema.

Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy would include (select all that apply) a. encouraging regular exercise such as swimming. b. washing around the stoma daily with a moist washcloth. c. emphasizing the importance of regular follow-up appointments d. providing pictures and "hands-on" instruction for tracheostomy care. e. having a list of emergency contact numbers and where to obtain supplies.

b,c,d,e

Nursing management of a patient with an oral ET tube would include a. maintaining ET tube cuff pressure at 35 to 40 cm H2O. b. routine suctioning of the ET tube at least every 2 hours. c. observing the patient for spontaneous respiratory effort and work of breathing. d. preventing ET tube dislodgment by limiting mouth care to lubrication of the lips.

c

The low tidal volume alarm on a client's ventilator keeps sounding. What is the nurse's first action? A) Manually ventilate the client .B) Put air into the endotracheal tube cuff. C) Check ventilator connections .D) Call the physician.

c

The major advantage of a Venturi mask is that it can a. deliver up to 80% O2. b. provide continuous 100% humidity. c. deliver a precise concentration of O2. d. be used while a patient eats and sleeps.

c

A patient is complaining of dyspnea, SOB, chest pain. What is the nurse's priority action a.) Apply the nasal cannula @ 2l/min b.) Notify the physician c.) Assess the vital signs and perform a physical assessment d.) Encourage the patient to cough and deep breathe

c D.) is correct but it is not the first action the nurse will take because the priority at the moment is to check the vital signs and do an assessment, whereas encouraging the patient to cough and deep breathing is an intervention (remember the nursing process).A.) is correct but is also an intervention which will occur after the nurse has gathered enough data through assessment.B.) Is not the correct option because the nurse does not have enough assessment data to give to the doctor and secondly the situation is within the scope of the nurse to handle.

The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur? A. The FiO2 will be increased. B. Weaning will continue .C. The client will be placed back on full ventilatory support. D. The client will be extubated.

c discontinue weaning bc pt is showing signs of intolerance

You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96.

c \ A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic. Option C is the answer because it states the patient's arterial oxygen level is remaining at 45 mmHg (a normal is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the patient can be tired and confused from a low oxygen level BUT this question wants to know the HALLMARK sign and symptom.

Immediate care priorities in the first few hours for a patient with a new tracheostomy include a. encouraging early mobility. b. changing the tracheostomy ties. c. suctioning the tracheostomy hourly. d. observing for bleeding at the insertion site.

d

The nurse admits a 35-year-old patient to the emergency department following a 3-day history of nausea and vomiting. Vital signs assessed by the nurse include a BP of 70/50 mm Hg, HR 145 beats/min, RR 36 breaths/min, and SpO2 of 92% on room air. The nurse recognizes which classification of shock? ● A.Cardiogenic B.Anaphylactic C.Obstructive D.Hypovolemic

d

The nurse is caring for a patient with severe sepsis. Vital signs assessed by the nurse include BP 88/60 mm Hg, HR 145 beats/min, RR 28 breaths/min, temperature 101° F, CVP 1 mm Hg, and SpO2 94% on 3 L/cannula. Which physician order should the nurse initiate first? ● A. Bedside glucose every 4 hours B. Tylenol 650 mg PR for temp > 101° F C. Urine culture and sensitivity D. 500 mL bolus of 0.9% normal saline

d

When assessing a patient in shock, the nurse recognizes that the hemodynamics of shock include: a.normal cardiac output in cardiogenic shock. b.increase in central venous pressure in hypovolemic shock. c.increase in systemic vascular resistance in all types of shock. d.variations in cardiac output and decreased systemic vascular resistance in septic shock.

d

A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement? A) Chest X-Ray B) Auscultation of breath sounds C) Pulse oximetry reading of 95% D) End tidal CO2 monitoring

d Rationale: End tidal CO2 monitoring is the first intervention to determine if the endotracheal tube is in place, but a chest x-ray is still needed to confirm proper placement.

A Client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assess the client for findings associated with a risk associated with this type of ventilator. What is the risk? A. Hypoventilation B. Hypercapnia C. Respiratory acidosis D. Barotrauma

d rationale: the volume-cycled ventilator has the potential to increase pressure in order to deliver the set volume. barotrauma is a risk associated with this form of mechanical ventilation. (Barotrauma also with High PEEP)

The nurse is caring for a patient in septic shock. Which hemodynamic change would the nurse expect? a.Increased ejection fraction. b.Increased mean arterial pressure. c.Decreased central venous pressure. d.Decreased systemic vascular resistance.

d BP depends on the stroke volume (amount of blood going out in one pump) and the Peripheral vascular resistance (like diameter of blood vessels) - basically it causes massive vasodilation so we would see decreased resistance

The nurse is caring for a critically ill patient. The nurse suspects that the patient has progressed beyond the compensatory stage of shock if what occurs? a.Decreased blood glucose levels b.Increased serum sodium levels c.Increased serum calcium levels d.Increased serum potassium levels

d Hyperkalemia occurs in the progressive phase of shock when cellular death liberates intracellular potassium. Hyperkalemia will also occur in acute kidney injury and in the presence of acidosis.

A patient admitted to the hospital from a long-term care facility appears to be in the late stage of shock with sepsis. Which order implemented by the nurse has the highest priority? a.Insert 2 large-bore IV catheters. b.Insert an indwelling urinary catheter. c.Start 0.9% normal saline at 100 mL/hr. Apply 100% oxygen by non-rebreather mask.

d. A patient in the irreversible stage of shock (late stage) will demonstrate profound hypotension and hypoxemia. If the condition progresses to systemic inflammatory response syndrome, the patient may experience profound hypoxemia. Oxygenation is a priority and should be initiated first with a 100% oxygen delivery method such as a non-rebreather mask.

The health care provider orders STAT ABGs. The results are as follows: pH 7.28, Paco2 55 mm Hg, Pao2 60 mm Hg, HCO3 25 mEq/L How would you interpret these ABGs?

respiratory acidosis