QUIZLET renal/burn/shock

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:

dislodge the autografts. Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.

A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek sign. What deficit does the nurse suspect the patient has?

Calcium

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: Breath sounds. Heart rate. Blood pressure. Renal output.

Correct response: Blood pressure. Explanation: By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.

Which type of shock is caused by an infection? Septic Anaphylactic Hypovolemic Cardiogenic

Correct response: Septic Explanation: Septic shock is caused by an infection. Cardiogenic shock occurs when the heart has an impaired pumping ability. Hypovolemic shock occurs when ththe intravascular volume has decreased. Anaphylactic shock is caused by a hypersensitivity reaction.

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: Vesicular breath sounds are audible in the lung periphery. Bilateral pedal pulses are 1+. The right foot is cooler than the left foot. The balloon deflates prior to systole.

Correct response: The right foot is cooler than the left foot. Explanation: When a client has an intra-aortic balloon counterpulsation, he or she is at risk for circulatory problems in the leg in which the catheter has been inserted. In this case, it is the right leg. A complication would be a right foot that is cooler than the left foot. Pedal pulses of 1+ bilaterally would not be a complication of this therapy but of other problems. The balloon is supposed to deflate prior to systole. It is normal for vesicular breath sounds to be audible in the lung periphery.

The primary presenting features of acute glomerulonephritis are hematuria, edema, azotemia (excessive nitrogenous wastes in the blood), and proteinuria (>3 to 5 g/day).

Decrease in the blood flow through the kidneys

Which of the following is the effect of protein catabolism in a client with severe burns?

It compromises wound healing and immunocompetence. Protein catabolism in a client with severe burns compromises wound healing and immunocompetence. Burns of the face, neck, or chest have the potential to impair ventilation, while burns involving the hands or major joints may affect dexterity and mobility. Release of aldosterone, not protein catabolism, causes sodium retention.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?

Natural Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?

Skin grafting will be necessary. In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?

Superficial A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate?

Tea-colored urine

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?

The early appearance of the burn injury may change. The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?

"Are the burns associated with chemicals used in the plant?" If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel.

After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?

"It is appropriate to warm the dialysate in a microwave."

An investment banker with chronic renal failure informs the nurse of the choice for continuous cyclic peritoneal dialysis. Which is the best response by the nurse?

"This type of dialysis will provide more independence."

When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area? 1 2 3 4

1

Which of the following is to be expected soon after a major burn? Select all that apply. Hypotension Tachycardia Anxiety Hypertension Bradycardia

1,2,3

Which type of graft utilizes the client's own skin for wound coverage? Heterograft Allograft Autograft Slit graft

3

The client with chronic renal failure complains of intense itching. Which assessment finding would indicate the need for further nursing education?

Brief, hot daily showers

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. 90 mm Hg 70 mm Hg 60 mm Hg 80 mm Hg

Correct response: 60 mm Hg Explanation: Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? Hormone antagonist drugs Antimetabolite drugs Adrenergic drugs Anticholinergic drugs

Correct response: Adrenergic drugs Explanation: Adrenergic drugs are the main medications used to treat shock.

Which colloid is expensive but rapidly expands plasma volume? Albumin Dextran Lactated Ringer solution Hypertonic saline

Correct response: Albumin Explanation: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?

Roll the client in a blanket. When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock? Obstructive Carcinogenic Hypovolemic Distributive

Correct response: Distributive Explanation: Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.

Which clinical finding should a nurse look for in a client with chronic renal failure?

Uremia Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure.

A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm? Proventil Benadryl Prednisone Epinephrine

Correct response: Epinephrine Explanation: Epinephrine is given for its vasoconstrictive actions, as well as for its rapid effect of reducing bronchospasm. Benadryl and Proventil (nebulized) are given to reverse the effects of histamine. Prednisone is given to reduce inflammation, if necessary.

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? Dilate the bronchial tree Slow the heart rate Increase the force of myocardial contraction Depress the central nervous system

Correct response: Increase the force of myocardial contraction Explanation: The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. Decreases in liver enzymes Reports of chest pain Loss in consciousness Ecchymoses and petechiae Increased paCO² levels

Correct response: Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae Explanation: The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activites of the liver are impaired, and liver enzymes will increase.

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? Irreversible Precompensatory Compensatory Progressive

Correct response: Irreversible Explanation: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? Compensatory Progressive Irreversible Refractory

Correct response: Progressive Explanation: In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.

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

Correct response: Use strict hand hygiene techniques. Explanation: The incidence of septic shock can be reduced by using strict infection control practices, beginning with thorough hand-hygiene techniques. Inserting an indwelling catheter would increase the risk of infection and thus of septic shock, not decrease it. Hand hygiene is more of a priority than administering prophylactic antibiotics. Masks would not prevent many types of infections.

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? Hemoglobin: 14.2 g/dL ESR: 19 mm/hour WBC: 42,000/mm3 Potassium: 4.8 mEq/L

Correct response: WBC: 42,000/mm3 Explanation: Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? compensatory respiratory alkalosis heart rate >20 bpm metabolic acidosis PaCO2 <32 mm Hg

Correct response: compensatory respiratory alkalosis Explanation: In the compnesatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The Pa CO2 would be increased in compensatory stage of shock. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid.

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock? anaphylactic shock septic shock neurogenic shock hypovolemic shock

Correct response: neurogenic shock Explanation: Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Septic shock is a subcategory of distributive shock, but it is associated with overwhelming bacterial infections. Anaphylactic shock is a subcategory of distributive shock, but it is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive, such as bee venom, latex, fish, nuts, and penicillin. Hypovolemic shock is not a subcategory of distributive shock. It occurs when the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma.

The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?

Dehydration The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration.

Which phase of acute renal failure signals that glomerular filtration has started to recover?

Diuretic The oliguric period is accompanied by an increase in the serum concentration of wastes such as urea, creatinine, organic acids, and the electrolytes potassium, phosphorous, and magnesium. The initiation period begins with the initial insult and ends when cellular injury and oliguria develops. The diuretic phase is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. The recovery period signals the improvement of renal function and energy level and may take 6 to 12 months.

Which type of burn injury requires skin grafting?

Full-thickness A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

What is the key sign of onset of acute respiratory distress syndrome?

Hypoxemia The key sign of the onset of acute respiratory distress syndrome (ARDS) is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.

Which of the following is a true statement regarding the purposes of skin grafts?

Reduces scarring and contractures.

The client with polycystic kidney disease asks the nurse, "Will my kidneys ever function normally again?" The best response by the nurse is:

"As the disease progresses, you will most likely require renal replacement therapy."

A client with end-stage renal disease is scheduled to undergo a kidney transplant using a sibling donated kidney. The client asks if immunosuppressive drugs can be avoided. Which is the best response by the nurse?

"Even a perfect match does not guarantee organ success."

A client with chronic renal failure comes to the clinic for a visit. During the visit, he complains of pruritus. Which suggestion by the nurse would be most appropriate?

"Keep your showers brief, patting your skin dry after showering."

A patient has acute kidney injury (AKI) with a negative nitrogen balance. How much weight does the nurse expect the patient to lose?

0.5 kg/day AKI causes severe nutritional imbalances (because nausea and vomiting contribute to inadequate dietary intake), impaired glucose use and protein synthesis, and increased tissue catabolism. The patient is weighed daily and loses 0.2 to 0.5 kg (0.5 to 1 lb) daily if the nitrogen balance is negative (i.e., caloric intake falls below caloric requirements).

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. What depth of burn injury does the client have? full thickness (third degree) superficial (first degree) superficial partial-thickness or deep partial-thickness (second degree) fourth degree

1

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 allograft silvadene application

1

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? Risk for Impaired Gas Exchange Acute Pain Risk for Infection Alteration in Tissue Perfusion

1

Burn shock is characterized by which of the following? Capillary leak Severe hypervolemia Organ hyperperfusion Elevated blood pressure (BP)

1

Following a burn injury, the nurse determines which area is the priority for nursing assessment? Pulmonary system Cardiovascular system Pain Nutrition

1

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? Roll the client in a blanket Cover the client with a wet cloth Place the client with the head positioned slightly below the rest of the body Avoid immediate IV fluid therapy

1

Which zone consists of the area where the injury is most severe and deepest? Coagulation Stasis Hyperemia Necrosis

1

When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area?

1 In clients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the client's palm, including the surface area of the digits, is approximately 1% of the total body surface area.

The palm represents which percentage of a person's TBSA?

1% A quick assessment technique is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's TBSA.

The nurse weighs a patient daily and measures urinary output every hour. The nurse notices a weight gain of 1.5 kg in a 74-kg patient over 48 hours. The nurse is aware that this weight gain is equivalent to the retention of:

1,500 mL of fluid A 1-kg weight gain is equal to 1,000 mL of retained fluid.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? Do nothing until the chemical agent is identified. Irrigate the wounds with water. Wash the wounds with soap and water and apply a barrier cream. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

2

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? Anemia Gastric ulcers Hyperthyroidism Cardiac arrest

2

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: Epidermal layer only. Epidermis and a portion of deeper dermis. Entire dermis and subcutaneous tissue. Dermis and connective tissue.

2

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? The client is in hypovolemic shock. The client has experienced extensive full-thickness burns. The paramedic administered high doses of opioids during transport. The client has experienced partial-thickness burns.

2

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? To prevent collapse and further injuries To keep fire and smoke from airway To extinguish flames more quickly To promote blood flow to the brain and vital organs

2

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? Age Weight Preexisting conditions Family history

3

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

A urinary output of 30 mL/hr For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).

In a client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?

Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. A BUN level of 100 mg/dl and a serum creatinine of 6.5 mg/dl are abnormally elevated results, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium

The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition?

Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop.

Which assessment finding is most important in determining nursing care for a client with acute glomerulonephritis?

Blurred vision Visual disturbances can be indicative of rising blood pressure in a client with acute glomerulonephritis. Severe hypertension needs prompt treatment to prevent convulsions. Presence of albumin (protein) and RBCs in the urine, along with periorbital and peripheral edema, are common symptoms associated with glomerulonephritis.

Diet modifications are part of nutritional therapy for the management of ARF. Select the high-potassium food that should be restricted.

Citrus fruits Dietary restrictions include foods and fluids containing potassium, such as bananas, citrus, tomatoes, melons, or those with phosphorus, which is found in dairy, beans, nuts legumes, and carbonated beverages. Caffeine is also restricted.

The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse?

Electrical burns usually follow an internal path. Electrical current follows the path of less resistance. Becausethe skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

Epidermis and a portion of deeper dermis. A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn.

Following a serious thermal burn, which complication will the nurse take action to prevent first?

Hypovolemia After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn.

What is a characteristic of the intrarenal category of acute kidney injury (AKI)?

Increased BUN The intrarenal category of acute kidney injury (AKI) encompasses an increased BUN, increased creatinine, a low-normal specific gravity of urine, and increased urine sodium. Intrarenal AKI is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN), AKI in which there is damage to the kidney tubules, is the most common type of intrinsic AKI. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

Lactated Ringer's solution Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase?

Oliguria During the second phase, the oliguric phase, oliguria occurs. Diuresis occurs during the third or diuretic phase. Acute tubular necrosis (ATN) occurs during the first, or initiation, phase in which reduced blood flow to the nephrons leads to ATN. Restoration of glomerular function, if it occurs, occurs during the fourth, or recovery, phase.

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?

Paralytic ileus Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

Which of the following occurs late in chronic glomerulonephritis?

Peripheral neuropathy Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with or without a pericardial friction rub. The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure.

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client?

Presence of soot around nasal passages If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed.

A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?

Recent history of streptococcal infection Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV).

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

Urine output of 20 ml/hour Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification

A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis?

Wear a mask when performing exchanges. The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection

A client is admitted to the hospital with a prerenal disorder, a nonurologic condition that disrupts renal blood flow to the nephrons, affecting their filtering ability. One cause of prerenal acute kidney injury is:

anaphylaxis Anaphylaxis is a cause of prerenal acute renal failure. Myoglobinuria secondary to burns is a cause of intrarenal acute renal failure. Polycystic disease is a cause of intrarenal acute renal failure. Ureteral stricture is a cause of postrenal acute renal failure.

A client has a family history of polycystic kidney disease. As the nurse gathers information and completes an assessment related to a polycystic kidney diagnosis, which findings would be expected? Select all that apply.

hypertension pain from retroperitoneal bleeding Hypertension is present in approximately 75% of affected clients at the time of diagnosis. Pain from retroperitoneal bleeding is caused by the size and effects of the cysts. Urinalysis shows mild proteinuria, hematuria, and pyuria. Renal stones are common.

A client diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering:

sodium polystyrene sulfonate (Kayexalate)

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?

Risk for infection The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products.

What is used to decrease potassium level seen in acute renal failure?

Sodium polystyrene sulfonate The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? Albumin Dextrose 5% in water (D5W) Lactated Ringer's solution Normal saline solution with 20 mEq of potassium per 1,000 ml

3

A child tips a pot of boiling water onto his bare legs. The mother should: Avoid touching the burned skin and take the child to the nearest emergency department. Cover the child's legs with ice cubes secured with a towel. Immerse the child's legs in cool water. Liberally apply butter or shortening to the burned areas.

3

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 36%. 27%. 18%. 9%.

3

Which of the following measures can be used to cool a burn? Application of cool water Application of ice directly to burn Wrapping the person in ice Using cold soaks or dressings for at least 1 hour

1

Which type of burn injury requires skin grafting? Full-thickness Superficial Superficial partial-thickness Deep partial-thickness

1

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching?

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated. The other statements indicate that teaching has been effective.

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply. Base-bicarbonate deficit Elevated hematocrit level Potassium deficit Sodium deficit Magnesium deficit

1,2,4

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 18% 27% 36% 45%

2

A patient has stage 3 chronic kidney failure. What would the nurse expect the patient's glomerular filtration rate (GFR) to be?

A GFR of 30-59 mL/min/1.73 m2

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? Kidneys Lungs Brain Liver

Correct response: Brain Explanation: The body displays a "fight-or-flight" response, with the release of catecholamines. Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain.

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? Circulatory (distributive) Hypovolemic Obstructive Carcinogenic

Correct response: Circulatory (distributive) Explanation: Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcatagories.

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply. Obstructive shock; kidney stone Neurogenic shock; diabetes Hypovolemic shock; blood loss Anaphylactic shock; nuts Cardiogenic shock; myocardial infarction Septic shock; infection

Correct response: Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nuts Septic shock; infection Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interfere in blood flow through the heart . Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? Pericardiocentesis Administration of oxygen via venture mask Intubation and mechanical ventilation Thoracotomy with chest tube insertion

Correct response: Intubation and mechanical ventilation Explanation: Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Periocardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? 0.9% sodium chloride Albumin Dextran Lactated Ringer's

Correct response: Lactated Ringer's Explanation: Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? Unable to measure Low Normal High

Correct response: Low Explanation: The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess Lung sounds Mental status Bowel sounds Skin perfusion

Correct response: Lung sounds Explanation: The nurse must monitor the client during fluid replacement for side effects and complications. The most common and serious side effects include cardiovascular overload and pulmonary edema, which would be exhibited as adventitious lung sounds. Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds.

The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? ScvO2 of 60% Urine output of 0.2 mL/kg/hr Mean arterial pressure of 70 mm Hg Central venous pressure of 6 mm Hg

Correct response: Mean arterial pressure of 70 mm Hg Explanation: The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.

Which positioning strategy should be used for the client diagnosed with hypovolemic shock? Supine Modified Trendelenburg Prone Semi-Fowler's

Correct response: Modified Trendelenburg Explanation: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? Increase in systolic blood pressure Narrowed pulse pressure Increase in diastolic pressure Decrease in respiratory rate

Correct response: Narrowed pulse pressure Explanation: Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume.

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? Anaphylactic Septic Neurogenic Cardiogenic

Correct response: Septic Explanation: In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.

The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately? The client's heart rate is greater than 90 beats per minute. The client's respiratory rate is less than 20 breaths per minute. The client feels restless and hungry. The client exhibits an increased urinary output.

Correct response: The client's heart rate is greater than 90 beats per minute. Explanation: A heart rate greater than 90 beats per minute or a respiratory rate greater than 20 breaths per minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output.

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? The difference between an apical and radial pulse The difference between the arterial and venous blood pressure The difference between the systolic and diastolic pressure The difference between an upper extremity and lower extremity blood pressure

Correct response: The difference between the systolic and diastolic pressure Explanation: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.

A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing? irreversible stage compensation stage cardiogenic shock decompensation stage

Correct response: decompensation stage Explanation: Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. This client's symptoms, particularly the dropping BP, indicate the decompensation stage. During the compensation stage of shock, physiologic mechanisms attempt to stabilize the spiraling consequences. During the irreversible stage, the client no longer responds to medical interventions, and multiple systems begin to fail. Cardiogenic shock is a type of shock.

A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing? neurogenic cardiogenic anaphylactic hypovolemic

Correct response: neurogenic Explanation: Neurogenic shock can be caused by spinal cord injury, spinal anesthesia, or other nervous system damage; client symptoms include dry skin and bradycardia with hypotension. Cardiogenic shock is seen in clients with impaired heart function. Hypovolemic shock is caused by decreased intravascular volume. Anaphylactic shock is caused by a severe allergic reaction; clients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen-antibody reaction; specifically, an immunoglobulin E-mediated response.

The nurse cares for a client with a right-arm arteriovenous fistula (AVF) for hemodialysis treatments. Which nursing action is contraindicated?

Obtaining a blood pressure reading from the right arm

What is a hallmark of the diagnosis of nephrotic syndrome?

Proteinuria Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur.

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?

Start IV fluids with a normal saline solution bolus followed by a maintenance dose. The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize.

Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.

Tall, peaked T waves

Which of the following is the most accurate indicator of fluid loss or gain?

Weight

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?

inflammatory The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:

fatigue and weakness.

The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder?

pH 7.20, PaCO2 36, HCO3 14- Metabolic acidosis occurs in end-stage kidney disease (ESKD) because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3-) and to reabsorb sodium bicarbonate (HCO3-). There is also decreased excretion of phosphates and other organic acids.

One of the roles of the nurse in caring for clients with chronic renal failure is to help them learn to minimize and manage potential complications. This would include:

restricting sources of potassium usually found in fresh fruits and vegetables.

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? inflammatory neuroendocrine intravascular fluid excess hypertension

1

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? BUN: 28 mg/dL K+: 5.0 mEq/L Na+: 145 mEq/L Ca: 9 mg/dL

1

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? Full-thickness Superficial Superficial partial-thickness Deep partial-thickness

1

As the first priority of care, a patient with a burn injury will initially need: a patent airway established. an indwelling catheter inserted. fluids replaced. pain medication administered.

1

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hyperkalemia. Hypernatremia. Hypocalcemia. Hypoglycemia.

1

In a client with burns on the legs, which nursing intervention helps prevent contractures? Applying knee splints Elevating the foot of the bed Hyperextending the client's palms Performing shoulder range-of-motion exercises

1

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? 9% 18% 27% 36%

3

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A urine output consistently above 40 ml/hour A weight gain of 4 lb (2 kg) in 24 hours Body temperature readings all within normal limits An electrocardiogram (ECG) showing no arrhythmias

1

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? Music therapy may provide reality orientation, distraction, and sensory stimulation. Music therapy diverts the client's attention toward painful stimulus. Humor therapy has not proven effective in the management of burn pain. Pet therapy has proven effective in the management of burn pain.

1

The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? Electrical burns usually follow an internal path. Lightning is higher in voltage than electricity. The skin is a good conductor of electricity. Moisture intensifies the damage inflicted.

1

Which antimicrobials is not commonly used to treat burns? tetracycline silver sulfadiazine (Silvadene) mafenide (Sulfamylon) silver nitrate (AgNO3) 0.5% solution

1

Which of the following is the effect of protein catabolism in a client with severe burns? It compromises wound healing and immunocompetence. It compromises dexterity and mobility. It maximizes the risk of sodium retention and hypotension. It maximizes the risk of impaired ventilation.

1

Which of the following is the preferred IV fluid for burn resuscitation? Lactated Ringer's (LR) Normal saline (NS) D5W Total parenteral nutrition (TPN)

1

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. Hourly urine output Daily weights Percentage of meals eaten Skin turgor Oxygen saturation

1,2,4

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? The client's heart rate is rapid and regular. The client's urinary output is 0.5 to 1 mL/kg/hour. The client's breathing is unlabored, and skin is clammy. The client is alert and conscious.

2

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? Classification by the appearance of blisters Identification by the destruction of the dermis and epidermis Not associated with edema formation Usually very painful because of exposed nerve endings

2

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 10 mL/hr A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr

2

Which of the following is a disadvantage of surgical debridement? Scarring Bleeding Loss of function Contractures

2

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? Mechanical Natural Enzymatic Surgical

2

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "Are the victims suffering from thermal burns?" "How many victims are anticipated for transport?" "Are the burns associated with chemicals used in the plant?" "Are any of the victims expected to have electrical burns?"

3

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame? 7 to 10 days 3 days 5 days 2 days

3

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? Removal of clothing Irrigation of the wound Application of ice Removal of hair

3

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." "I will drink a lot of fluids to prevent constipation since I am taking pain medications." "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." "I can work with the social worker to find funding assistance programs to help with my medical expenses."

3

The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies? Hypernatremia Hypokalemia Hyperkalemia Hypercalcemia

3

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? Diverticulitis Hematemesis Paralytic ileus Ulcerative colitis

3

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? It helps determine the percentage of the total body surface area (TBSA) that is burned. The client's condition is likely to deteriorate after 72 hours. The wound is susceptible to infections. The early appearance of the burn injury may change.

4

A nurse formulates a nursing diagnosis of Impaired physical mobilityfor a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to fat emboli Related to infection Related to femoral artery occlusion Related to circumferential eschar

4

A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care? The client's serum sodium levels are elevated. The client exhibits metabolic alkalosis. The client's urinary output has fallen below 30 ml/hour. The client's complete blood count readings reflect a reduced hematocrit.

4

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? 9% 18% 27% 36%

4

Following a serious thermal burn, which complication will the nurse take action to prevent first? Tissue hypoxia Infection Renal failure Hypovolemia

4

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? Mederma Integra Transcyte Biobrane

4

Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis?

Azotemia The primary presenting features of acute glomerulonephritis are hematuria, edema, azotemia (excessive nitrogenous wastes in the blood), and proteinuria (>3 to 5 g/day).

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? "Infuse I.V. fluids at 83 ml/hour." "Administer oxygen by nasal cannula at 3 L/minute." "Monitor urine output every hour." "Draw samples for hemoglobin and hematocrit every 6 hours."

Correct response: "Infuse I.V. fluids at 83 ml/hour." Explanation: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct? "The client is in shock because the heart is unable to circulate the body fluids." "The client is in shock because your loved one is not responding and brain dead." "The client is in shock because all peripheral blood vessels have massively dilated." "The client is in shock because the blood volume has decreased in the system."

Correct response: "The client is in shock because the blood volume has decreased in the system." Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first? Type and cross match C-spine x-rays 100% oxygen via a nonrebreather mask Two large-bore IVs and begin crystalloid fluids

Correct response: 100% oxygen via a nonrebreather mask Explanation: The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied via a nonrebreather mask. The other orders should be completed after the client's airway is secure.

The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour? 5.5 mL/hr 2.7 mL/hr 8.0 mL/hr 11 mL/hr.

Correct response: 2.7 mL/hr Explanation: The nurse should administer 2.7 mL/hr: 1 mcg/90 kg/60 minutes/2,000 (concentration)

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? Thready 24 Palpable Within normal limits

Correct response: 24 Explanation: The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24. The pulse pressure does not report quality of the pulse.

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? 60% 50% 70% 40%

Correct response: 70% Explanation: Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: Arrhythmias. Cardiomyopathies. Valvular damage. A myocardial infarction.

Correct response: A myocardial infarction. Explanation: Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

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

Correct response: A rapid, bounding pulse Explanation: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible and pulse rhythm changes from regular to irregular.

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? A weak and thready pulse A slow and imperceptible pulse A slow but steady pulse A rapid, bounding pulse

Correct response: A rapid, bounding pulse Explanation: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? Begin a continuous IV infusion of insulin per protocol. Initiate enteral feedings as prescribed. Administer recombinant human activated protein C (rhAPC) as prescribed. Administer norepinephrine as prescribed.

Correct response: Administer norepinephrine as prescribed. Explanation: Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next Calls the Rapid Response Team Contacts the admitting physician Administers oxygen by nasal cannula at 2 liters per minute Re-assesses the vital signs

Correct response: Administers oxygen by nasal cannula at 2 liters per minute Explanation: The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage? Lactated Ringer solution Albumin Hypertonic saline Dextran

Correct response: Albumin Explanation: Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared with crystalloid solutions. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

Which type of shock occurs from an antigen-antibody response? Neurogenic Anaphylactic Cardiogenic Septic

Correct response: Anaphylactic Explanation: During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? Hypertension Aortic insufficiency Unstable angina pectoris Diabetes mellitus

Correct response: Aortic insufficiency Explanation: A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP.

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. Administer vasoconstrictive medications to clients at risk for shock. Administer prophylactic packed red blood cells to clients at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs. Assess the client who is at risk for shock.

Correct response: Assess the client who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs. Explanation: Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock? Hypovolemic Obstructive Cardiogenic Circulatory (distributive)

Correct response: Circulatory (distributive) Explanation: Vasodilatation, a prominent characteristic of circulatory/distributive shock, increases the space in the vascular bed. Central blood flow is reduced because peripheral vascular or interstitial areas exceed their usual capacity. Vasodilation is not a major component of cardiogenic, hypovolemic, or obstructive shock.

At what point in shock does metabolic acidosis occur? Compensation Irreversible Early Decompensation (Progressive)

Correct response: Decompensation (Progressive) Explanation: The decompensation or progressive stage occurs as compensatory mechanisms fail. The client's condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis. Therefore, options A, B, and C are incorrect.

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is Salt-poor albumin Hetastarch Packed red blood cells Dextran

Correct response: Dextran Explanation: Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to Encourage the family to touch and talk to the client. Inform the family that everything is being done to assist with the client's survival. Open up discussion among the family members about nursing home placement. Contact a spiritual advisor to provide comfort to the family.

Correct response: Encourage the family to touch and talk to the client. Explanation: The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? Head injury Myocardial infarction Multiple sclerosis Diabetes

Correct response: Head injury Explanation: An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries.

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption? Limit interaction with visitors. Arrange personal care supplies nearby. Maintain activity restriction to bedrest. Avoid heavy meals.

Correct response: Maintain activity restriction to bedrest. Explanation: Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity.

In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? Nitroprusside Epinephrine Dopamine Methoxamine

Correct response: Nitroprusside Explanation: A disadvantage of nitroprusside (Nipride) is that it causes hypotension. Dopamine (Intropin) improves contractility, increases stroke volume, and increases cardiac output. Epinephrine (Adrenaline) improves contractility, increases stroke volume, and increases cardiac output. Methoxamine (Vasoxyl) increases blood pressure by vasoconstriction.

In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart? Methoxamine Epinephrine Nitroprusside Dopamine

Correct response: Nitroprusside Explanation: A disadvantage of nitroprusside is that it causes hypotension. Dopamine and epinephrine improve contractility, increase stroke volume, and increase cardiac output. Methoxamine increases blood pressure by vasoconstriction.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: Morphine 2 mg intravenously Oxygen at 2 L/min by nasal cannula Dopamine (Intropin) intravenous solution NS at 60 mL/hr via an intravenous line

Correct response: Oxygen at 2 L/min by nasal cannula Explanation: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

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

Correct response: Progressive Explanation: In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.

The nurse is caring for a client in the compensation stage of shock. The nurse knows that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do? Increases catecholamine secretion Restores blood pressure Decreases peripheral blood flow Increases the production of antidiuretic hormone

Correct response: Restores blood pressure Explanation: The renin-angiotensin-aldosterone systemis a mechanism that restores blood pressure (BP) when circulating volume is diminished. It does not decrease peripheral blood flow, increase catecholamine secretion, or increase the production of antidiuretic hormone.

What is the major clinical use of dobutamine? treat hypotension. prevent sinus bradycardia. increase cardiac output. treat hypertension.

Correct response: increase cardiac output. Explanation: Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn mediciations would the nurse administer next? loperamide ondansetron meperidine magnesium hydroxide

Correct response: ondansetron Explanation: An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? organ damage unsteady gait liver dysfunction weight loss

Correct response: organ damage Explanation: When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.

The client with chronic renal failure is exhibiting signs of anemia. Which is the best nursing rationale for this symptom?

Diminished erythropoietin production

A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?

Increase carbohydrates and limit protein intake. Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood.

When assessing the impact of medications on the etiology of acute renal failure, the nurse recognizes which of the following as the drug that is not nephrotoxic?

Penicillin The three nephrotoxic drugs are aminoglycerides.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:

Replace lost fluids and electrolytes. After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?

Risk for Impaired Gas Exchange During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: planning for the client's rehabilitation and discharge. providing emotional support to the client and family. maintaining the client's fluid, electrolyte, and acid-base balance. preserving full range of motion in all affected joints.

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Question 3 See full question 35s A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36% The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: fluid resuscitation. infection. body image. pain management.

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When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst Moderate to severe pain Urine output of 70 ml the first hour Hoarseness of the voice

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The nurse is caring for a client with chronic kidney disease. The patient has gained 4 kg in the past 3 days. In milliliters, how much fluid retention does this equal? __________________

4000 A 1-kg weight gain is equal to 1,000 mL of retained fluid. 4 kg × 1,000 = 4,000. The most accurate indicator of fluid loss or gain in an acutely ill patient is weight.

Sevelamer hydrochloride (Renagel) has been prescribed for a client with chronic renal failure. The physician has prescribed Renagel 800 mg orally three times per day with meals to treat the client's hyperphosphatemia. The medication is available in 400 mg tablets. How many tablets per day will the nurse administer to the client?

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A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder?

Acute glomerulonephritis Acute glomerulonephritis is also associated with varicella zoster virus, hepatitis B, and Epstein-Barr virus. Acute renal failure is associated with hypoperfusion to the kidney, parenchymal damage to the glomeruli or tubules, and obstruction at a point distal to the kidney. Chronic renal failure may be caused by systemic disease, hereditary lesions, medications, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis.

When preparing a client for hemodialysis, which of the following would be most important for the nurse to do?

Check for thrill or bruit over the access site. When preparing a client for hemodialysis, the nurse would need to check for a thrill or bruit over the vascular access site to ensure patency. Inspecting the catheter insertion site for infection, adding the prescribed drug to the dialysate, and warming the solution to body temperature would be necessary when preparing a client for peritoneal dialysis.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:

Hyperkalemia. Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

A client is diagnosed with polycystic kidney disease. Which of the following would the nurse most likely assess?

Hypertension Hypertension is present in approximately 75% of clients with polycystic kidney disease at the time of diagnosis. Pain from retroperitoneal bleeding, lumbar discomfort, and abdominal pain also may be noted based on the size and effects of the cysts

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain?

Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain.

Specific potential complications are common to specific types of burns. Which burns can impair ventilation?

face, neck, chest Burns of the face, neck, or chest have the potential to impair ventilation.

Rejection of a transplanted kidney within 24 hours after transplant is termed

hyperacute rejection. Hyperacute rejection may require removal of the transplanted kidney. Acute rejection occurs within 3 to 14 days of transplantation. Chronic rejection occurs after many years.