TEST 2

A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames? A 8 weeks B 2 to 4 weeks C 1 week D 6 weeks

2 to 4 weeks Explanation: For deep partial-thickness burn injuries, recovery is expected in 2 to 4 weeks.

A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation? A "How many alcoholic drinks do you typically consume in a week?" B "Have you ever worked in an occupation where you might have been exposed to toxins?" C "To the best of your knowledge, are your immunizations up to date?" D "Has anyone in your family ever experienced symptoms similar to yours?"

"How many alcoholic drinks do you typically consume in a week?" Explanation: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.

Which of the following liver function studies is used to show the size of the liver and hepatic blood flow and obstruction A Angiography B MRI C Radioisotope liver scan D EEG

Radioisotope liver scan Explanation: A radioisotope liver scan assesses liver size and hepatic blood flow and obstuction. A MRI is used to identify normal structures and abnormalities of the liver and biliary tree. An angiography is used to visualize hepatic circulation and detect the presence and nature of hepatic masses. An EEG is used to detect abnormalities that occur with hepatic coma.

Which laboratory study is used to detect pancreatic injury? A Serum amylase B Urinalysis C Hemoglobin and hematocrit D White blood cell count

Serum amylase Explanation: Serum amylase analysis is done to detect increasing levels of the amylase enzyme, which suggest pancreatic injury or perforation of the GI tract. A white blood cell count is done to detect an elevation. A urinalysis is done to detect hematuria. A hemoglobin and hematocrit is done to evaluate trends reflecting the presence or absence of bleeding.

A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A Destruction of the patient's liver tumor B Restoration of portal vein patency C Reversal of metastasis D Destruction of a liver abscess

Destruction of the patient's liver tumor Explanation: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.

The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? Superficial Partial-thickness superficial Partial-thickness deep Full thickness

Full thickness Question 1 Explanation: The characteristics of the wound meet the criteria for a full-thickness injury (color that is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm and inelastic).

The nurse identifies which of the following types of jaundice in an adult experiencing a transfusion reaction? A Hepatocellular B Hemolytic C Obstructive D Nonobstructive

Hemolytic Explanation: Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

Which of the following is the recommended dietary treatment for a client with chronic cholecystitis? A Low-protein diet B Low-fat diet C Low-residue diet D High-fiber diet

Low-fat diet Explanation: The bile secreted from the gallbladder helps the body absorb and break down dietary fats. If the gallbladder is not functioning properly, then it will not secrete enough bile to help digest the dietary fat. This can lead to further complications; therefore, a diet low in fat can be used to prevent complications. A low-fat diet is recommended because a malfunctioning gallbladder will not secrete sufficient bile to breakdown dietary fats.

To reduce risk of injury for a patient with liver disease, what initial measure can the nurse implement? A Raise all four side rails on the bed B Prevent visitors, so as not to agitate the patient C Apply soft wrist restraints D Pad the side rails on the bed

Pad the side rails on the bed Explanation: Padding the side rails can reduce injury if the patient becomes agitated or restless. Restraints would not be an initial measure to implement. Four side rails are considered a restraint and this would not be an initial measure to implement. Family and friends most generally assist in calming a patient.

A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a patient's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The patient is placed in a high Fowler's position and a BP cuff is secured around the arm in preparation for which of the following procedures? A Abdominal ultrasound B Dialysis C Paracentesis D Liver biopsy

Paracentesis Explanation: Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise.

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do? Apply antiembolic stockings. Place the client in a sitting position. Notify the physician. Lay the client flat.

Place the client in a sitting position. Explanation: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.

A male patient presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the patient has an injury to his pancreas. Which of the following laboratory studies is used to detect pancreatic injury? a White blood cell count b Urinalysis C Hemoglobin and hematocrit D Serum amylase

Serum amylase Explanation: Serum amylase analysis is done to detect increasing levels, which suggests pancreatic injury or perforation of the GI tract. A white blood cell count is done to detect an elevation. A urinalysis is done to detect hematuria. A hemoglobin and hematocrit test is done to evaluate trends reflecting the presence or absence of bleeding.

Why should total parental nutrition (TPN) be used cautiously in clients with pancreatitis? A Such clients are at risk for gallbladder contraction. B Such clients can digest high-fat foods. C Such clients cannot tolerate high-glucose concentration. D Such clients are at risk for hepatic encephalopathy.

Such clients cannot tolerate high-glucose concentration. Explanation: Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Ringer's lactate at 150 cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient? A Diuretics B Arterial line C Volume expanders D Foley catheter

Volume expanders Explanation: Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Diuretics would reduce vascular volume. An arterial line and Foley catheter are likely to be ordered, but neither actively maintains the patient's volume.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The following describes one of the injury zones: the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. What is the name of that zone? A Zone of stasis B Zone of coagulation C Zone of hypotension D Zone of hyperemia

Zone of stasis Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. This is not the name of one of the zones.

Which of the following provides clues about fluid volume status? Select all that apply. A Oxygen saturation B Skin turgor C Percentage of meals eaten D Hourly urine output E Daily weights

Hourly urine output Daily weights Explanation: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. A Facial burns B Singed nasal hair C Yellow sputum D Bradypnea E Hoarseness

Singed nasal hair Hoarseness Facial burns Explanation: Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.

What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures? "For the first few days after surgery, the donor sites will be painful." "Because the graft is my own skin, there is no chance it won't 'take'." "I will have some scarring in the area when the skin is removed for grafting." "Once all grafting is completed, my risk for infection is the same as it was before I was burned."

"Because the graft is my own skin, there is no chance it won't 'take'." Factors other than tissue type, such as circulation and infection, influence whether and how well a graft "takes." The client should be prepared for the possibility that not all grafting procedures will be successful.

The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintain to retain maximum function of this joint? Hip maintained in 30-degree flexion, no knee flexion Hip flexed 90 degrees and knee flexed 90 degrees Hip, knee, and ankle all at maximum flexion Hip at zero flexion with leg flat

Hip at zero flexion with leg flat Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree of flexion.

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. The nurse understands that a likely cause of her symptoms is ________. A hepatitis A B pancreatitis C acute cholecystitis D hepatitis B

acute cholecystitis Explanation: Gallstones are more frequent in women, particularly women who are middle-aged and obese. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain that may radiate to the back and shoulders. The patient profile and symptoms are suggestive of acute cholecystitis.

A patient is scheduled for an allograft to a burn wound. The patient asks what an allograft is. Which of the following information will the nurse include in the explanation? A "An allograft is a temporary wound covering obtained from pig skin." B "An allograft is a permanent wound covering taken from a donor site in your body." C "An allograft is a temporary wound covering obtained from cadaver skin." D "An allograft is an expensive sheet of skin obtained from a culture."

"An allograft is a temporary wound covering obtained from cadaver skin." Explanation: There are several different temporary and permanent coverings for burn wounds. Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). Therefore, the body's immune response will eventually reject them as a foreign substance.

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

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

The nurse is caring for a patient following an SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction? "I can apply powder under the liner to help with sweating." "If a pin becomes detached, I'll notify the surgeon." "I'll check under the liner for blisters and redness." "I will change the vest liner periodically."

"I can apply powder under the liner to help with sweating." Explanation: The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness causes skin excoriation. The liner should be changed periodically to promote hygiene and good skin care. Powder is not used inside the vest because it may contribute to the development of pressure ulcers.

A client with posttraumatic stress disorder has been complaining of headaches. A physician orders magnetic resonance imaging (MRI) of the brain to rule out organic disorders. The client later tells a nurse, "I'm not going into that tunnel!" Which response by the nurse is most therapeutic? "The MRI exam is the most accurate and complete test to find out what is causing your headaches." "The tunnel is going to remind you of something from your past." "If you take several slow, deep breaths and close your eyes, it will reduce your anxiety." "I can tell you're really afraid. Can you tell me more about your fear?"

"I can tell you're really afraid. Can you tell me more about your fear?" Explanation: The client is experiencing intense fear. Rather than reasoning with the client, the nurse should use the refusal as an opportunity to learn more about his or her feelings. Acknowledging the client's expressed fears both focuses on the feelings and encourages the client to talk about those feelings. Expressing feelings may make the client more receptive to the MRI. Telling the client that an MRI is the only way a physician can detect physical problems would likely increase the client's resistance to the procedure. Using the technique of repeating may assure the client that the nurse understands the feelings but does not encourage further exploration of those feelings. Taking deep breaths might benefit the client at a later time, but this suggestion disregards and discounts the currently expressed fear.

A newly admitted 20-year-old client, diagnosed with posttraumatic stress disorder (PTSD), reluctantly reveals that she escaped from a cult 2 years ago. The client says, "Nobody will ever believe the horrible things the men did to me, and no one never stopped them." Which response is appropriate for the nurse to make? "I will believe anything you tell me. You can trust me." "I cannot understand why your mother did not protect you. It is not right." "Tell me about the cult. I did not know there were any near here." "It must be difficult to talk about what happened. I am willing to listen."

"It must be difficult to talk about what happened. I am willing to listen." Explanation: Survivors of trauma/torture have a lot of difficulty with trust and do not readily talk about the horrible events. Therefore, empathy and a willingness to listen without pressuring the client are crucial. Believing everything may or may not be possible and does not convey the empathy. It is sometimes difficult to believe what satanic cults can do to children. Saying that it was not right that members did not help diverts attention from the client to the member. Asking to hear about the cult shows more interest in the cult than the client

A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply. A "This medication will help my burn heal." B "This medication will stain my skin permanently." C "This medication is an antibacterial." D "This medication will be applied directly to the wound."

"This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal." Explanation: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the patient's skin, but it will help heal the patient's burned areas.

The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurse's best response? "To increase the urine output and prevent kidney damage." "To stimulate intestinal movement and prevent abdominal bloating." "To decrease hydrochloric acid production in the stomach and prevent ulcers." "To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock."

"To decrease hydrochloric acid production in the stomach and prevent ulcers." Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.

A patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the patient's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma. A 2, 3, 1, 4, 5 B 3, 1, 2, 5, 4 C 1, 2, 5, 4, 3 D 1, 2, 3, 4, 5

1, 2, 3, 4, 5 Explanation: Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure unless he or she receives a liver transplant.

A nurse is teaching a patient about the types of chronic liver disease. The patient's teaching is determined to be effective based on the correct identification of which of the following types of cirrhosis caused by scar tissue surrounding the portal areas? A Compensated cirrhosis B Alcoholic cirrhosis C Biliary cirrhosis D Postnecrotic cirrhosis

Alcoholic cirrhosis Explanation: Alcoholic cirrhosis, in which the scar tissue characteristically surrounds the portal areas, is most frequently caused by chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

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

Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply. Provide sedation to family members as needed. Talk with the family about the client having "passed on." Allow the family to express their emotions freely. Ask the family if they would like to view the body. Provide a private place for the family to be together.

Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely. Explanation: When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities in a trauma patient effectively. Which of the following actions is completed by the nurse when implementing the "D" element of this method? Assessing the patient's Glasgow Coma Scale Undressing the patient quickly Providing cervical spine protection Managing hypothermia

Assessing the patient's Glasgow Coma Scale Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the patient alert and responsive? V, verbal: does the patient respond to verbal stimuli? P, pain: does the patient respond only to painful stimuli? U, unresponsive: is the patient unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.

A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patient's prioritization for receiving a donor liver be determined? A By systematically ruling out alternative treatment options B By objectively assessing the patient's willingness to adhere to post-transplantation care C By objectively determining the patient's medical need D By considering the patient's age and prognosis

By objectively determining the patient's medical need Explanation: The patient would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MELD) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence, and the rejection of alternative options.

Which of the following actions is a quick assessment technique that the nurse might use to assess the percentage of a small or scattered burn injury? A Checking the patient's vital signs B Comparing the patient's palm with the size of the burn wound C Observing the color of the patient's wound D Observing the patient's level of consciousness

Comparing the patient's palm with the size of the burn wound Explanation: A quick technique to assess the percentage of burn injury is to compare the patient's palm with the size of the burn wound. In patients with scattered burns, the Palmer method may be used to estimate the extent of the burns. The size of the patient's hand, including the fingers, is approximately 1% of that patient's total body surface area (TBSA). Observing the color of the patient's wound, checking the patient's vital signs, and observing the patient's level of consciousness determine the patient's health status, but do not help assess the percentage of burn injury.

The nurse is providing care for a patent with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the patient is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. The nurse's best response based on the clinical findings is which of the following? A Elevate the leg on pillows and reassess the leg in 1 hour. B Contact the primary care provider and prepare for an escharotomy. C Apply an elastic stocking to the extremity and administer SQ heparin per order. D Document the findings and instruct the patient to report numbness of the extremity.

Contact the primary care provider and prepare for an escharotomy. Explanation: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.

Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? Colloids Crystalloids Fresh-frozen plasma Packed red blood cells

Crystalloids Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringer's lactate. The burn client rarely requires blood during the emergent phase unless the burn is complicated by another injury that involved hemorrhage. Colloids and plasma are not generally used during the fluid shift phase because these large particles pass through the leaky capillaries into the interstitial fluid, where they increase the osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen the capillary leak syndrome and make maintaining the circulating fluid volume even more difficult.

Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure? Select all that apply. Establish an airway for ventilation Prevent aspiration into the lungs Facilitate removal of an upper airway obstruction Allow connection to a manual resuscitation bag Decrease tracheobronchial secretions

Establish an airway for ventilation Allow connection to a manual resuscitation bag Prevent aspiration into the lungs Explanation: Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection to a resuscitation bag or mechanical ventilator, or facilitate removal of tracheobronchial secretions.

An 85-year-old patient is admitted to the ED. Heat stroke is suspected. The patient's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the patient will include which of the following? Endotracheal intubation with mechanical ventilation IV hydration with normal saline solution Immersion of the patient in a cold-water bath Administration of sodium supplements

Immersion of the patient in a cold-water bath Explanation: For the patient with heat stroke, simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing) (formerly called the ABCs) of basic life support. This includes establishing IV access for fluid administration. After the patient's clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour. One or more of the following methods may be used as prescribed: Cool sheets and towels or continuous sponging with cool water; ice applied to the neck, groin, chest, and axillae while spraying with tepid water; and cooling blankets. Immersion of the patient in a cold-water bath is the optimal method for cooling (if available). Hydration would be with lactated Ringer's solution. There is no indication for intubation. Administration of sodium supplements is indicated for the treatment of heat cramps.

A client has been diagnosed with posttraumatic stress disorder (PTSD) because he experienced childhood sexual abuse (CSA) by his babysitter and her boyfriend from ages 4 to 10. He is admitted for the second time after physically assaulting a woman he said was a prostitute. "She is no better than my babysitter and deserves to be dead. I would like to kill the sitter too." With the knowledge of PTSD and CSA, which nursing interventions should be implemented at admission? Select all that apply. In one-to-one staff talks, encourage him to safely verbalize his anger toward his babysitter and her boyfriend. Provide safe outlets for his anger and rage. Ask the client to sign a no harm contract. Institute precautions for suicide, assault, and escape. Encourage him to express his attitude toward prostitutes during unit group settings.

Institute precautions for suicide, assault, and escape. Ask the client to sign a no harm contract. Provide safe outlets for his anger and rage. In one-to-one staff talks, encourage him to safely verbalize his anger toward his babysitter and her boyfriend. Explanation: Anger and rage could be directed at self and others. He implies that he did nothing wrong in assaulting the woman (denial) and may try to leave without treatment. A No Harm Contract is essential for everyone's safety. He needs safe outlets, including staff talks, for his anger. Talking about his views of prostitutes in unit groups may be upsetting to female clients who have sexual abuse issues as well, so this needs to occur in private.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A Implement interventions aimed at ensuring a calm and therapeutic care environment. B Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. C Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. D Ensure that the patient's sodium intake does not exceed recommended levels.

Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. Explanation: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patient's physiologic deterioration.

Which of the following are characteristics of autonomic dysreflexia? Severe hypertension, tachycardia, blurred vision, dry skin Severe hypotension, slow heart rate, anxiety, dry skin Severe hypertension, slow heart rate, pounding headache, sweating Severe hypotension, tachycardia, nausea, flushed skin

Severe hypertension, slow heart rate, pounding headache, sweating Explanation: Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension and tachycardia would occur. Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Bradycardia and flushed skin would occur. Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension and flushed skin would occur.

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client? A Spironolactone (Aldactone) B Lactulose (Cephulac) C Propranolol (Inderal) D Vasopressin (Pitressin)

Vasopressin (Pitressin) Explanation: In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Vasopressin (Pitressin) may be the initial mode of therapy in urgent situations, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Lactulose (Cephulac) is administered to reduce serum ammonia levels in clients with hepatic encephalopathy.

Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? A Liver transplantation B Lobectomy C Cryosurgery D Laser hyperthermia

Lobectomy Explanation: Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.

Which of the following topical burn preparations act as wick for sodium and potassium? A Mafenide acetate (Sulfamylon) B Silver sulfadiazine (Silvadene) C Silver nitrate solution D Acticoat

Silver nitrate solution Explanation: Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium.

When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA? 1 3 2 2 3 4 4 .5

.5 Explanation: In patients 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 patient's palm, not including the surface area of the digits, is approximately 0.5% of the TBSA.

A patient has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? A Within 12 hours after surgery B 2 to 5 days after surgery C As soon as sanguineous drainage is noted D Within 24 hours after surgery

2 to 5 days after surgery Explanation: The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively

Permanent brain injury or death will occur within which timeframe secondary to hypoxia? A 9 to 10 minutes B 6 to 8 minutes C 3 to 5 minutes D 1 to 2 minutes

3 to 5 minutes Explanation: If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. The other timeframes are incorrect.

The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury?

3422 Explanation: Convert pounds. to kilograms = 130/2.2 = 59 kg 2 mL × 59 kg × 58% TBSA = 6844 mL/24 hr. 6844/2 = 3422, so the nurse will administer 3422 mL over the first 8 hours and the remaining 3422 mL over the next 16 hours. The infusion is regulated so that one-half of the calculated volume is administered in the first 8 hours after burn injury. The second half of the calculated volume is administered over the next 16 hours. Fluid resuscitation formulas are only a guideline. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response.

A patient presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following? A 27% B 18% C 36% D 9%

36% Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the TBSA, quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%).

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe? A 2 days B 7 to 10 days C 3 days D 5 days

5 days Explanation: Acticoat antimicrobial barrier dressings can be left in place for up to 5 days thus helping to decrease discomfort to the patient, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.

A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? A Administration of fresh-frozen plasma (FFP) B Administration of immune globulins C A regimen of antiviral medications D Rest and watchful waiting

A regimen of antiviral medications Explanation: There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that a combination of two antiviral agents, Peg-interferon and ribavirin (Rebetol), is effective in producing improvement in patients with hepatitis C and in treating relapses. Immune globulins and FFP are not indicated.

A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A Finish all prescribed courses of antibiotics, regardless of symptom resolution. B Adhere to dosing recommendations of OTC analgesics. C Ensure that pharmacists regularly review drug regimens for potential interactions. D Ensure that expired medications are disposed of safely.

Adhere to dosing recommendations of OTC analgesics. Explanation: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis.

A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan? A Vitamin B12 injections as ordered B Administration of diuretics as ordered C Mobilization with assistance at least 4 times daily D Administration of beta-adrenergic blockers as ordered

Administration of diuretics as ordered Explanation: Use of diuretics along with sodium restriction is successful in 90% of patients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Select the graft described as the following: a biologic source of skin similar to that of the client. A Allograft B Slit graft C Xenograft D Autograft

Allograft Explanation: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

The nurse is assessing a patient with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply. A Complaints of headache B Alterations in mood C Decreased deep tendon reflexes D Agitation E Insomnia

Alterations in mood Agitation Insomnia Explanation: The earliest symptoms of hepatic encephalopathy include both mental status changes and motor disturbances. The patient appears confused and unkempt and has alterations in mood and sleep patterns. The patient tends to sleep during the day and has restlessness and insomnia at night. To assess for mental deterioration, the nurse will assess general behavior, orientation, and speech as well as cognitive abilities and speech patterns.

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following? A Calcium B Alcohol C Bicarbonate D Ammonia

Ammonia Explanation: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Cephulac does not influence calcium, bicarbonate, or alcohol levels.

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position? Approximately at the patient's lips At the level of the patient's epiglottis Directly in front of the patient's teeth Just below the tip of the patient's nose

Approximately at the patient's lips Explanation: When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient's lips.

When should ambulation be initiated in the client who has sustained a major burn? When all full-thickness areas have been closed with skin grafts When the client's temperature has remained normal for 24 hours As soon as possible after wound debridement is complete As soon as possible after resolution of the fluid shift

As soon as possible after resolution of the fluid shift Regular, progressive ambulation is initiated for all burn clients who do not have contraindications concomitant injuries as soon as the fluid shift resolves. Clients can be ambulated with extensive dressings, open wounds, and nearly any type of attached lines, tubing, and other equipment.

Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction? A Asterixis B Paracentesis C Ascites D Dialysis

Asterixis Explanation: Asterixis refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances

The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply. A Heart rate B Oxygen saturation C Blood pressure D Urine output

Blood pressure Heart rate Urine output Explanation: Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits

A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful? Brachial Subclavian Radial Femoral

Brachial Explanation: The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.

At which of the following spinal cord injury levels does the patient have full head and neck control? C5 C3 C4 C2

C5 Explanation: At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.

What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire? Pulse oximetry reading of 80% Expiratory stridor and nasal flaring Cherry red color to the mucous membranes Presence of carbonaceous particles in the sputum

Cherry red color to the mucous membranes The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a "cherry red" color of the mucous membranes in these clients. The other manifestations are associated with inhalation injury, but not specifically carbon monoxide poisoning.

A male client on a neurologic unit is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for his condition, he is unable to move his lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Expected outcomes of care would include all of the following, except? Client regains bowel elimination capacity. Client's skin will remain clean, dry and intact, or without breakdown. Client maintains mechanical ventilation with minimal mucus accumulation. Client states he has no discomfort.

Client maintains mechanical ventilation with minimal mucus accumulation. Explanation: A client with a lumbar spinal injury would not require mechanical ventilation. This would be an expected outcome of care for a client with a spinal injury.

Which of the following terms refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery? Crush injuries Intra-abdominal injuries Blunt trauma Penetrating abdominal injuries

Crush injuries Explanation: Crush injuries are those that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery. Blunt trauma is commonly associated with extra-abdominal injuries to the chest, head, or extremities. Penetrating abdominal injuries include those such as gunshot and stab wounds. Intra-abdominal injuries are categorized as penetrating and blunt trauma.

Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns? A Protein cell coagulation B Continuing inflammatory process C Deep tissue cooling D All options are correct.

Deep tissue cooling Explanation: Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding? Bradycardia Delayed capillary refill Rising blood pressure Pale pink dry skin

Delayed capillary refill Explanation: If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.

Which of the following statements reflects the nursing management of the patient with a white phosphorus chemical burn? Alternate applications of water and ice to the burn Do not apply water to the burn Wash off the chemical using warm water, and then flush the skin with cool water Immediately drench the skin with running water from a shower, hose or faucet

Do not apply water to the burn Explanation: Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

ithin the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation? A All options are correct. B Perineal C Face, neck, chest D Hands, major joints

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

he mode of transmission of hepatitis A virus (HAV) includes which of the following? A Saliva B Semen C Fecal-oral D Blood

Fecal-oral Explanation: The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.

Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have? A Superficial partial-thickness and deep partial-thickness (second degree) B Superficial (first degree) C Fourth degree D Full thickness (third degree)

Full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appears charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

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? A Superficial partial-thickness B Full-thickness C Deep partial-thickness D Superficial

Full-thickness Explanation: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. 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 froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. Being struck with a baseball bat Gunshot wound Fall from a roof Knife-stab wound Motor-vehicle crash

Gunshot wound Knife-stab wound Explanation: Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.

Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds? Handwashing on entering the client's room Encouraging the client to cough and deep breathe Administering the prescribed tetanus toxoid vaccine Changing gloves between cleansing different burn areas

Handwashing on entering the client's room Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Although all the interventions listed above can help reduce the risk for infection, only hand washing can prevent cross contamination.

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? A Refusal to lie flat B Wheezing between coughs C Forceful coughing D High-pitched noise on inhalation

High-pitched noise on inhalation Explanation: A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such.

The nurse is assigned to care for patients with SCI on a rehabilitation unit. Which of the following does the nurse recognize are clinical manifestations of autonomic dysreflexia? Select all that apply. Diaphoresis Nasal congestion Hypertension Tachycardia Fever

Hypertension Diaphoresis Nasal congestion Explanation: Hypertension and diaphoresis are signs of autonomic dysreflexia. Nasal congestion often accompanies autonomic dysreflexia. Bradycardia, not tachycardia, occurs with autonomic dysreflexia. Although the patient may be diaphoretic, a fever does not accompany this condition.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? A Hypotension B Warm moist skin C Bradycardia D Polyuria

Hypotension Explanation: Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased BP, and decreased urine output.

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

Hypotension Tachycardia Anxiety Explanation: Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply. Stridor Cyanosis Clutching of the neck Inability to speak Spontaneous coughing

Inability to speak Clutching of the neck Stridor Cyanosis Explanation: Manifestations of a complete airway obstruction include the inability to speak, breathe, or cough; clutching the neck; inspiratory and expiratory stridor; and cyanosis (a late sign). If the client can cough spontaneously, then a partial airway obstruction is most likely.

During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? Increased wound pain 30 to 40 minutes after drug application Presence of small, pale pink bumps in the wound beds Decreased white blood cell count Increased serum creatinine level

Increased serum creatinine level Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored.

Which zone of burn injury sustains the most damage? A Middle B Inner C Outer D Protective

Inner Explanation: Each burned area has three zones of injury. The inner zone (known as the area of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.

A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? a Give the patient a cold beverage to promote swallowing ability. b Keep patient NPO until the patient's gag reflex returns. c Administer analgesia until post-procedure tenderness is relieved. d Keep patient NPO until the results of test are known.

Keep patient NPO until the patient's gag reflex returns. Explanation: After the examination, fluids are not given until the patient's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patient's physical condition and mental status permit. The result of the test is known immediately. Food and fluids are contraindicated until the gag reflex returns.

Louie, with burns over 35% of the body, complains of chilling. In promoting the client's comfort, the nurse should: Maintain room humidity below 40% Place top sheet on the client Limit the occurrence of drafts Keep room temperature at 80 degrees

Limit the occurrence of drafts A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.

The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action? Administer oxygen. Loosen the dressing. Notify the emergency team. Document the observation as the only action.

Loosen the dressing. Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client's respiratory status.

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. Which of the following is an important education topic regarding ingestion of medications? A The need for increased drug dosages B The need for more frequently divided doses C Metabolism of medications D Medications will no longer be effective in clients with liver disease.

Metabolism of medications Explanation: Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? A Moisten with saline. B Use topical antimicrobials with Acticoat burn dressing. C Keep Acticoat saturated. D Moisten with sterile water only.

Moisten with sterile water only. Explanation: Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.

The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? Seasonal asthma Hepatitis B 10 years ago Myocardial infarction 1 year ago Kidney stones within the last 6 month

Myocardial infarction 1 year ago It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation.

A client is being seen in the clinic after returning from military service abroad. The nurse documents restlessness at night with nightmares leaving the veteran irritable and fatigued during the day. When discussing the possibility of posttraumatic stress disorder (PTSD), which statements about PTSD are accurate? Select all that apply. PTSD is a syndrome that affects only those who have experienced traumatic episodes during war. Substance abuse is a common coping mechanism used by clients with PTSD. Hypervigilance is characteristic of clients with PTSD. Psychotic episodes can occur in clients with PTSD. Clients with PTSD may complain of feeling empty inside. PTSD is characterized by nightmares and flashbacks.

PTSD is characterized by nightmares and flashbacks. Hypervigilance is characteristic of clients with PTSD. Substance abuse is a common coping mechanism used by clients with PTSD. Psychotic episodes can occur in clients with PTSD. Clients with PTSD may complain of feeling empty inside. Explanation: PTSD is a serious condition that develops after a person has witnessed a traumatic or terrifying event in which serious physical harm has occurred or is threatened. Although PTSD is commonly associated with combat, it can manifest itself after any kind of trauma. If symptoms occur within 6 months of the traumatic event, the disorder is considered acute. If symptoms occur more than 6 months after the traumatic event, PTSD is considered delayed or chronic. PTSD is characterized by nightmares or flashbacks. Clients are hypervigilant but typically describe themselves as "empty inside." Sometimes, the events can present as a psychotic episode. Substance abuse is a common "symptom" used for coping.

Which of the following terms describes the passage of a hollow instrument into a cavity for the withdrawal of fluid? A Dialysis B Asterixis C Ascites D Paracentesis

Paracentesis Explanation: Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise. Asterixis refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances.

The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? Superficial Partial-thickness superficial Partial-thickness deep Full thickness

Partial-thickness superficial The characteristics of the wound meet the criteria for a superficial partialthickness injury (color that is pink or red; blisters; pain present and high).

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Choose all that apply. A Roll the client in a blanket to smother the fire. B Open door and encourage air in an enclosed space. C Place the client in a horizontal position. D Place the client in a vertical position.

Place the client in a horizontal position. Roll the client in a blanket to smother the fire. Explanation: If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from: Adjustment disorder Somatoform Disorder Generalized Anxiety Disorder Post traumatic disorder

Post traumatic disorder Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event.

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for? Urinary tract infection Rebound hypotension Rebound hypertension Spinal shock

Rebound hypotension Explanation: When the cause is removed and the symptoms abate, the blood pressure goes down. The antihyperstensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.

A nurse is establishing a patient's airway. Which action would the nurse perform first? Repositioning the patient's head Giving abdominal thrusts Using the jaw-thrust maneuver Inserting an artificial airway

Repositioning the patient's head Explanation: Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust manuever, or insertion of an artificial airway.

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn? Covering the area with a sterile dressing Rinsing the area with copious amounts of water Applying antimicrobial ointment Administering tetanus prophylaxis

Rinsing the area with copious amounts of water Explanation: The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn.

All of the following laboratory test results on a burned client's blood are present during the emergent phase. Which result should the nurse report to the physician immediately? Serum sodium elevated to 131 mmol/L (mEq/L) Serum potassium 7.5 mmol/L (mEq/L) Arterial pH is 7.32 Hematocrit is 52%

Serum potassium 7.5 mmol/L (mEq/L) All these findings are abnormal; however, only the serum potassium level is changed to the degree that serious, life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death.

A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following? A Can be left in place for 3 to 5 days B Blood levels of sodium and potassium will be monitored. C Stains clothing D Severe burning pain for up to 20 minutes

Severe burning pain for up to 20 minutes Explanation: The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored.

Which of the following are the immediate complications of spinal cord injury? Spinal shock Paraplegia Tetraplegia Respiratory arrest

Spinal shock Explanation: Respiratory arrest and spinal shock are the immediate complications of spinal cord injury. Tetraplegia is paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury.

Which of the following is a potential cause of a superficial partial-thickness burn? A Sunburn B Scald C Flash flame D Electrical current

Sunburn Explanation: A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? T10 L4 T6 S2

T6 Explanation: Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

ll of the following are antimicrobials commonly used to treat burns except: A Silver nitrate (AgNO3) 0.5% solution B Mafenide (Sulfamylon) C Tetracycline D Silver sulfadiazine (Silvadene)

Tetracycline Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? Injuries have occurred to at least three distinct organ systems. The most lethal injuries are often the most readily apparent. The client is assumed to have a spinal cord injury until proven otherwise. Most multiple trauma victims exhibit evidence of the trauma.

The client is assumed to have a spinal cord injury until proven otherwise. Explanation: With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma cleints experience life-threatening injuries to at least two distinct organs or organ systems. Evidence of the trauma may be sparse or absent. Additionally, the injury that may seem the least significant may be the most lethal.

Which information obtained by assessment ensures that the client's respiratory efforts are currently adequate? The client is able to talk. The client is alert and oriented. The client's oxygen saturation is 97%. The client's chest movements are uninhibited

The client's oxygen saturation is 97%. Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.

The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? The medication will be effective more quickly than if given intramuscularly. It is less likely to interfere with the client's breathing and oxygenation. The danger of an overdose during fluid remobilization is reduced. The client delayed gastric emptying.

The danger of an overdose during fluid remobilization is reduced. Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A The patient will exercise three times a week. B The patient will take immunosuppressive agents as required. C The patient will obtain measurement of drainage from the T-tube. D The patient will monitor for signs of liver dysfunction.

The patient will take immunosuppressive agents as required. Explanation: The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to ensure that an adequate supply of medication is available so that there is no chance of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as the patient wouldn't go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress these topics over the immunosuppressive drug regimen.

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A Absence of blood or mucus in stool B Two to 3 soft bowel movements daily C Absence of nausea and vomiting D Significant increase in appetite and food intake

Two to 3 soft bowel movements daily Explanation: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patient's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.

Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? Vitamin A Vitamin B Vitamin C Vitamin D

Vitamin D Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in full thickness burns.

The burned client's family ask at what point the client will no longer be at increased risk for infection. What is the nurse's best response? "When fluid remobilization has started." "When the burn wounds are closed." "When IV fluids are discontinued." "When body weight is normal."

"When the burn wounds are closed." Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open.

When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)? 1 4 2 2 3 1 4 3

1 Explanation: In patients 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 patient's palm, not including the surface area of the digits, is approximately 1% of the TBSA.

Which of the following terms is used to describe a chronic liver disease in which scar tissue surrounds the portal areas? A Biliary cirrhosis B Compensated cirrhosis C Postnecrotic cirrhosis D Alcoholic cirrhosis

Alcoholic cirrhosis Explanation: This type of cirrhosis is due to chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

Which of the following stimuli is known to trigger an episode of autonomic dysreflexia in the patient who has suffered a spinal cord injury? Placing the patient in a sitting position Diarrhea Voiding Applying a blanket over the patient

Applying a blanket over the patient Explanation: An object on the skin or skin pressure may precipitate an autonomic dysreflexic episode. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the patient is observed to be demonstrating signs of autonomic dysreflexia, he is placed in a sitting position immediately to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include? Assessing neurologic function Providing adequate ventilation Establishing a patent airway Applying electrocardiogram electrodes

Applying electrocardiogram electrodes Explanation: A secondary survey is completed after the primary survey priorities of airway, breathing, circulation, and disability have been addressed. Applying electrocardiogram electrodes would be a component of the secondary survey. Establishing a patent airway, providing adequate ventilation, and determining neurologic disability by assessing neurologic function are components of the primary survey.

When is the first dressing change at the site of an autograft performed? A As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery B Within 12 hours after surgery C Within 24 hours after surgery D As soon as sanguineous drainage is noted

As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery Explanation: A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately. The first dressing change usually occurs 2 to 5 days after surgery. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? Spinal shock Autonomic dysreflexia Thrombophlebitis Orthostatic hypotension

Autonomic dysreflexia Explanation: Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.

The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except? Being an athlete Male gender Alcohol/drug use Young age

Being an athlete Explanation: The predominant risk factors for SCI include young age (most between 16 and 30 years old), gender (80% of those living with SCI are male), and alcohol/drug use.

A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern? A Ca: 9 mg/dL B K+: 5.0 mEq/L C BUN: 28 mg/dL D Na+: 145 mEq/L

BUN: 28 mg/dL Explanation: The elevated BUN would case the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, which is associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn? The burn is full thickness rather than partial thickness. The client is unable to fully pronate and supinate the extremity. Capillary refill is slow in the digits and the distal pulse is absent. The client cannot distinguish the sensation of sharp versus dull in the extremity.

Capillary refill is slow in the digits and the distal pulse is absent. Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure and preventing blood flow to the distal extremities and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb. This problem can be reduced or corrected with an escharotomy.

A client is brought to the emergency department with severe hemorrhage requiring masssive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following? Cardiac arrest Fluid overload Hyperthermia Hemolytic transfusion reaction

Cardiac arrest Explanation: Blood must be warmed in a commercial blood warmer because administration of large amounts of blood that has been refigerated has a core cooling effect that may lead to cardiac arrest and coagulopathy. Hyperthermia, hemolytic transfusion reaction, or fluid overload is not the concern.

A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk? A Hepatomegaly B Pigment stones in portal circulation C Chronic jaundice D Central nervous system damage

Central nervous system damage Explanation: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin.

Which of the following would be the most important nursing assessment in a patient diagnosed with ascites? A Palpation of abdomen for a fluid shift B Auscultation of abdomen C Daily weight and measurement of abdominal girth D Assessment of oral cavity for foul-smelling breath

Daily weight and measurement of abdominal girth Explanation: Daily measurement and recording of abdominal girth and body weight are essential to assess the progression of ascites and its response to treatment.

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A Assessments for signs and symptoms of venous thromboembolism B Assessment of blood pressure and assessment for headaches and visual changes C Daily weights and abdominal girth measurement D Blood glucose monitoring q4h

Daily weights and abdominal girth measurement Explanation: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.

Which of the following is an age-related change of the hepatobiliary system? A Increased drug clearance capability B Liver enlargement C Decreased blood flow D Decreased prevalence of gallstones

Decreased blood flow Explanation: Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gallstones, and a steady decrease in size and weight of the liver.

When the ED nurse learns that a patient suffered a burn injury from a flash flame, the nurse anticipates which depth of burn? A Deep partial thickness B Superficial C Full thickness D Superficial partial thickness

Deep partial thickness Explanation: A deep partial thickness burn, which is similar to a second-degree burn, is associated with scalds and flash flames. Superficial partial thickness burns, similar to first-degree burns are associated with sunburns. Full thickness burns, similar to third-degree burns, are associated with direct flame, electricity, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? Working in a chemical plant Diving in an ocean Swimming in a lake Running a race in hot humid weather

Diving in an ocean Explanation: Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowing episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis? A Fourth degree B Superficial partial-thickness C Deep partial-thickness D Full-thickness

Deep partial-thickness Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.

A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following? A Continuous monitoring for portal hypertension B Delivery of a continuous chemotherapeutic dose C Real-time monitoring of vascular changes in the hepatic system D Administration of immunosuppressive drugs during the first weeks after transplantation

Delivery of a continuous chemotherapeutic dose Explanation: In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system.

A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A Destruction of a liver abscess B Reversal of metastasis C Restoration of portal vein patency D Destruction of the patient's liver tumor

Destruction of the patient's liver tumor Explanation: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.

Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse's best action? Reposition the client onto the right side. Document the finding as the only action. Notify the emergency team. Increase the IV flow rate.

Document the finding as the only action. Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response, and it is not the highest priority of care at this time.

Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse's best action? Notify the emergency team. Document the finding as the only action. Ask the client if anyone in her family has diabetes mellitus. Slow the intravenous infusion of dextrose 5% in Ringer's lactate.

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

A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? A Document the presence of normal bile output. B Promptly report this assessment finding to the primary care provider. C Aspirate a sample of the drainage for culture. D Irrigate the drainage system with normal saline as ordered.

Document the presence of normal bile output. Explanation: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.

A nurse is developing a plan of care for a patient diagnosed with post-traumatic stress disorder (PTSD). Which of the following would be the priority? Assisting the patient to work through the traumatic experience Teaching coping skills for self-care Establishing a trusting nurse-patient relationship Administering prescribed drug therapy

Establishing a trusting nurse-patient relationship Explanation: The priority when caring for a patient with PTSD is establishing a trusting nurse-patient relationship, because the patient is physically compromised and struggling emotionally with situations that are not considered part of the normal human experience. Once trust is established, then the nurse can assist the patient in working through the traumatic experience, teach coping skills for recovery and self-care, and administer prescribed medications.

A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? White blood cell count of 300/mm3 Red blood cell count of 50,000/mm3 Absence of bile Evidence of feces

Evidence of feces Explanation: A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3.

On admission to the emergency department the burned client's blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury-related response? Fluid shift Intense pain Hemorrhage Carbon monoxide poisoning

Fluid shift Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage is unusual in a burn injury. The physiologic effect of histamine release in injured tissues is a loss of vascular volume to the interstitial space, with a resulting decrease in blood pressure.

Which of the following would be the least important assessment in a patient diagnosed with ascites? A Measurement of abdominal girth B Weight C Palpation of abdomen for a fluid shift D Foul-smelling breath

Foul-smelling breath Explanation: Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.

A nursing student is reviewing for an upcoming anatomy and physiology examination. Which of the following would the student correctly identify as a function of the liver? Select all that apply. A Glucose metabolism B Zinc storage C Protein metabolism D Carbohydrate metabolism E Ammonia conversion

Glucose metabolism Ammonia conversion Protein metabolism Explanation: Functions of the liver include the metabolism of glucose, protein, fat, and drugs; conversion of ammonia; storage of vitamins and iron; formation of bile; and excretion of bilirubin. The liver is not responsible for the metabolism of carbohydrates or the storage of zinc.

The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury? Place a towel roll under the client's neck or shoulder. Keep the client in a supine position without the use of pillows. Have the client turn the head from side to side 90 degrees every hour while awake. Keep the client in a semi-Fowler's position and actively raise the arms above the head every hour while awake.

Have the client turn the head from side to side 90 degrees every hour while awake. The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion.

The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission? Airway patency Heart rate and rhythm Orientation to time, place, and person Current range of motion in all extremities

Heart rate and rhythm The airway is not at any particular risk with this injury. Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes.

Which of the following is the key sign of onset of ARDS? A Chest pain B Tachypnea C Hypoxemia D Stridor

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

What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury? Acute Pain Impaired Adjustment Deficient Diversional Activity Imbalanced Nutrition: Less than Body Requirements

Impaired Adjustment Recovery from a burn injury requires a lot of work on the part of the client and significant others. Seldom is the client restored to the preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client. By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem.

A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A Implementation of infection-control measures B Administration of antiretroviral medications C Frequent assessment of the patient's psychosocial status D Close monitoring of skin integrity and color

Implementation of infection-control measures Explanation: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated.

A nurse is assessing a patient with posttraumatic stress disorder (PTSD) who is exhibiting physiologic manifestations. The nurse interprets these manifestations as being the result of which of the following? Decreased plasma catecholamine levels Decreased urinary epinephrine levels Increased sympathetic activity Increased parasympathetic activity

Increased sympathetic activity Explanation: The physiologic responses associated with PTSD result from increased activity of the sympathetic nervous system, increased plasma catecholamine levels, and increased urinary epinephrine and norepinephrine levels.

Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery? Increased urine output, decreased urine specific gravity Increased peripheral edema, decreased blood pressure Decreased peripheral pulses, slow capillary refill Decreased serum sodium level, increased hematocrit

Increased urine output, decreased urine specific gravity The "fluid remobilization" phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity.

A 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury? A Hypertension B Intravascular fluid excess C Neuroendocrine D Inflammatory

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

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? Lactated Ringer's solution Hypertonic saline Dextrose 5% in water Type O negative blood

Lactated Ringer's solution Explanation: Replacement fluids may include isotonic electrolyte solutions and blood component therapy. O negative blood is prepared for emergency use in women of childbearing age.Dextrose 5% in water should not be used to replace fluids in hypovolemic patients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

What is the most frequently injured solid organ in a penetrating trauma? Brain Lungs Pancreas Liver

Liver Explanation: The most frequently injured solid organ in a penetrating trauma is the liver.

A homeless client at the neighborhood clinic has a lengthy history of alcohol addiction and is being seen for jaundice. Which of the following would the appearance of jaundice most likely indicate? A Bile overproduction B Glucose underproduction C Gallbladder disease D Liver disorder

Liver disorder Explanation: Jaundice is a sign of disease, but it is not itself a unique disease. Jaundice accompanies many diseases that directly or indirectly affect the liver and is probably the most common sign of a liver disorder.

A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? A Liver transplantation B IV administration of immune globulins C Lobectomy D Transfusion of packed red blood cells and fresh-frozen plasma (FFP)

Liver transplantation Explanation: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? A Maintaining the airway B Maintaining fluid volume C Controlling bleeding D Relieving the patient's anxiety

Maintaining the airway Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway is compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? Massaging the feet Placing sterile cotton between the toes after rewarming Providing an analgesic for pain Restricting ambulation

Massaging the feet Explanation: For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.

Which of the following is the analgesic of choice for burn pain? A Fentanyl B Demerol C Morphine sulfate D Tylenol with codeine

Morphine sulfate Explanation: Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

An emergency nurse has collected evidence from a patient who was shot during a robbery. The nurse is preparing to transfer the evidence to law enforcement. Which of the following would be important for the nurse to include when documenting this transfer? Select all that apply. Date that the evidence was collected The labels placed on the collection bags Time of the transfer of evidence Family members who witnessed the transfer Name of the law-enforcement official

Name of the law-enforcement official Date that the evidence was collected Time of the transfer of evidence Explanation: When transferring evidence to law enforcement, the nurse must document the chain of custody. This includes the information that evidence was transferred to the officer, the officer's name, and the date and time of the transfer. Labels are placed on each item, but this does not need to be documented for the transfer. The names of family members witnessing the transfer also do not need to be documented.

The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse's best action? Nothing, because the findings are normal for clients during the acute phase of recovery. Increase the temperature in the room and increase the IV infusion rate. Assess the client's airway and oxygen saturation. Notify the burn emergency team.

Notify the burn emergency team. These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention.

Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the: Total volume of circulating whole blood Total volume of intravascular plasma Permeability of capillary walls Permeability of kidney tubules

Permeability of capillary walls In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.

A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? A Place hand under right lower rib cage and press down lightly with the other hand. B Place hand under the right lower abdominal quadrant and press down lightly with the other hand. C Hold hand 90 degrees to right side of the abdomen and push down firmly. D Place the left hand over the abdomen and behind the left side at the 11th rib.

Place hand under right lower rib cage and press down lightly with the other hand. Explanation: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.

The most common cause of esophageal varices includes which of the following? A Asterixis B Portal hypertension C Jaundice D Ascites

Portal hypertension Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

Connie, a 60-year-old retired financial planner, is recently diagnosed with carcinoma of the pancreas. She has just met with her surgeon and feels overwhelmed by all the information she was given. She tells you that she is having the head of the pancreas removed; additionally, the surgeon is also removing the duodenum and stomach and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is Connie having performed? A Distal pancreatectomy B Radical pancreatoduodenectomy C Total pancreatectomy D Cholecystojejunostomy

Radical pancreatoduodenectomy Explanation: This surgical procedure involves removing the head of the pancreas, resecting the duodenum and stomach, and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the jejunum. This surgical procedure is a rerouting of the pancreatic and biliary drainage systems, which may be done to relieve obstructive jaundice. This measure is considered palliative only. A pancreatectomy is the surgical removal of the pancreas. A pancreatectomy may be total, in which case the entire organ is removed, usually along with the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. A distal pancreatectomy is a surgical procedure to remove the bottom half of the pancreas.

Which of the following liver function studies is used to show the size of the liver and hepatic blood flow and obstruction? A Electroencephalogram (EEG) B Angiography C Radioisotope liver scan D Magnetic resonance imaging (MRI)

Radioisotope liver scan Explanation: A radioisotope liver scan assesses liver size and hepatic blood flow and obstruction. An MRI is used to identify normal structures and abnormalities of the liver and biliary tree. Angiography is used to visualize hepatic circulation and detect the presence and nature of hepatic masses. An EEG is used to detect abnormalities that occur with hepatic coma.

What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm? Risk for Ineffective Breathing Pattern Decreased Tissue Perfusion Risk for Disuse Syndrome Disturbed Body Image

Risk for Disuse Syndrome During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury.

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

Roll the patient in a blanket Explanation: At the scene of a fire, the patient should be rolled in a blanket to smother the fire. The patient should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The patient 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.

Which of the following symptoms will a nurse observe most commonly in clients with pancreatitis? A Severe, radiating abdominal pain B Increased appetite and weight gain C Increased and painful urination D Black, tarry stools and dark urine

Severe, radiating abdominal pain Explanation: The most common symptom in clients with pancreatitis is severe midabdominal to upper abdominal pain, radiating to both sides and straight to the back.

A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A Stage 2 B Stage 3 C Stage 1 D Stage 4

Stage 3 Explanation: Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.

A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion? Denuded skin Skin tear with irregular edges and vein bridging Incision of the skin with well-defined edges, usually longer than deep Tearing away of tissue from supporting structures

Tearing away of tissue from supporting structures Explanation: An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually longer than deep.

In reviewing the burned client's laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis? The total white blood cell count is 9000/mm3. The lymphocytes outnumber the basophils. The "bands" outnumber the "segs." The monocyte count is 1,800/mm3.

The "bands" outnumber the "segs." Normally, the mature segmented neutrophils ("segs") are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood count. Fewer than 3% to 5% of the circulating white blood cells should be the less mature "band" neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. Such a shift indicates severe infection or sepsis, in which the client's immune system cannot keep pace with the infectious process.

Which client factors should alert the nurse to potential increased complications with a burn injury? The client is a 26-year-old male. The client has had a burn injury in the past. The burned areas include the hands and perineum. The burn took place in an open field and ignited the client's clothing.

The burned areas include the hands and perineum. Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome.

Which of the following data is most important for the nurse to record while assessing a patient with an open wound? Time and place of the injury Vital signs of the patient Degree of movement and range of motion Time when the patient last received a tetanus immunization

Time when the patient last received a tetanus immunization Explanation: If the patient has an open wound, the nurse ascertains when the patient last received a tetanus immunization. This vital information helps in assessing the risk of infection in a patient with an open wound. The assessment begins with taking vital signs if the patient experiences a traumatic injury. It is important to ascertain the time and place of injury with the degree of movement and range of motion in all cases, not just in case of an open wound.

Which of the following diagnostic studies definitely confirms the presence of ascites? A Abdominal x-ray B Colonoscopy C Ultrasound of liver and abdomen D Computed tomography of abdomen

Ultrasound of liver and abdomen Explanation: Ultrasonography of the liver and abdomen will definitively confirm the presence of ascites. An abdominal x-ray, colonoscopy, and computed tomography of the abdomen would not confirm the presence of ascites.

A triage nurse determines that a client with non-life-threatening injuries requires imaging studies and moderate sedation. The triage nurse would document this client as which of the following? Resuscitation Emergent Urgent Nonurgent

Urgent Explanation: Clients who have non-life-threatening conditions but require two or more resouces to provide their care would be classified as urgent. In this situation, the client would be considered urgent becuase he requires imaging studies (one resource) and moderate sedation (a two-resource procedure). Clients in the resuscitation category need treatment immediately to prevent death. Clients in the emergent category may deteriorate rapidly and develop a major life-threatening situation or may require time-sensitive treatment. Clients in the nonurgent category have non-life-threatening conditions and likely need only one resource to provide for their needs.

Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? A Vasopressin (Pitressin) B Cimetidine (Tagamet) C Nitroglycerin D Spironolactone (Aldactone)

Vasopressin (Pitressin) Explanation: Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.

Which of the following is an early sign of sepsis in the burn injured patient? A Clammy skin B Hypothermia C Increased pulse rate D Widened pulse pressure

Widened pulse pressure Explanation: The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the patient's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas.

Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery? Changing gloves between wound care on different parts of the client's body. Avoiding sharing equipment such as blood pressure cuffs between clients. Using the closed method of burn wound management. Using proper and consistent handwashing.

Changing gloves between wound care on different parts of the client's body. Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on difference parts of the client's body can prevent autocontamination.

The nurse is conducting a secondary survey on a patient in the ED. Which of the following is completed during the secondary survey? A Diagnostic and laboratory testing B Assessment of peripheral pulses C Undressing the patient D Establishing a patent airway

Diagnostic and laboratory testing Explanation: During the secondary survey, diagnostic and laboratory testing is completed. The other interventions are completed during the primary survey.

What additional laboratory test should be performed on any African American client who sustains a serious burn injury? Total protein Tissue type antigens Prostate specific antigen Hemoglobin S electrophoresis

Hemoglobin S electrophoresis Sickle cell disease and sickle cell trait are more common among African Americans. Although clients with sickle cell disease usually know their status, the client with sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur in the emergent phase of a burn injury could result in decreased tissue perfusion that is sufficient to cause sickling of cells, even in a person who only has the trait. Determining the client's sickle cell status by checking the percentage of hemoglobin S is essential for any African American client who has a burn injury.

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations? A Portal hypertension B Hepatitis C C Esophageal varices D Hepatic encephalopathy

Hepatic encephalopathy Explanation: The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The client appears slightly confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult.

The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following? A Sodium and water retention caused by increase adrenocortical activity B Liquid blood component is lost into extravascular space C Decreased renal blood flow D Fluid loss

Liquid blood component is lost into extravascular space Explanation: Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity.

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply. Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx Patient who is bleeding from the chest Patient with extensive facial trauma Patient with a lumbar spine injury

Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx Explanation: Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find? Spontaneous coughing High-pitched noises on inhalation Severe respiratory distress Cyanosis

Spontaneous coughing Explanation: If a patient can breathe and cough spontaneously, a partial airway obstruction should be suspected. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were a complete airway obstruction.

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to A increase metabolic rate. B increase glucose demands. C increase skeletal muscle breakdown. D decrease catabolism.

decrease catabolism. Explanation: The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

Which of the following complications is common for victims of electrical burns? A Hypovolemic shock B Inhalation injury C Infection D Cardiac dysrhythmia

Cardiac dysrhythmia Explanation: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

When caring for a patient with cirrhosis, which of the following symptoms should the nurse report immediately? A Change in mental status B Fatigue and weight loss C Diarrhea or constipation D Anorexia and dyspepsia

Change in mental status Explanation: When caring for a patient with cirrhosis, the nurse should report any change in mental status immediately because they indicate secondary complications. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable? Cherry red skin color Confusion Palpitations Headache

Cherry red skin color Explanation: Skin color can range from pink or cherry-red to cyanotic and pale is not a reliable sign. In clients with carbon monoxide poisoning, central nervous system signs such as headache and confusion predominate. Palpitations also may occur.

Which statement by the client indicates correct understanding of rehabilitation after burn injury? "I will never be fully recovered from the burn." "I am considered fully recovered when all the wounds are closed." "I will be fully recovered when I am able to perform all the activities I did before my injury." "I will be fully recovered when I achieve the highest possible level of functioning that I can."

"I will be fully recovered when I achieve the highest possible level of functioning that I can." Although a return to pre burn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning.

In assessing the client's potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission? "Are you a smoker?" "When was your last chest x-ray?" "Have you ever had asthma or any other lung problem?" "In what exact place or space were you when you were burned?"

"In what exact place or space were you when you were burned?" The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms. although smoking increases the risk for some problems, it does not predispose the client for an inhalation injury.

A nurse is providing wound care to a patient who arrived at the emergency department after being hit by flying glass from a broken window. The nurse asks the patient about his last tetanus shot. Which statement would indicate to the nurse that the patient needs a tetanus booster? "It must be at least 6 or 7 years since I had one." "I just had a tetanus shot last year when I cut my foot on a piece of metal." "My last tetanus shot was 2 1/2 years ago during a check-up." "I had one last month after I was injured at work."

"It must be at least 6 or 7 years since I had one." Explanation: Tetanus prophylaxis is administered as prescribed, based on the condition of the wound and the patient's immunization status. If the patient's last tetanus booster was administered more than 5 years ago, or if the patient's immunization status is unknown, he or she requires a tetanus booster. Thus, the patient's statement about it being at least 6 or 7 years would indicate to the nurse that the patient needs a booster immunization.

Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment? "After this treatment, my ears will not stick out." "The mask will help protect my skin from sun damage." "Using this mask will prevent scars from being permanent." "My facial scars should be less severe with the use of this mask."

"My facial scars should be less severe with the use of this mask." The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not change the angle of ear attachment to the head.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? A Hemolytic B Hepatocellular C Nonobstructive D Obstructive

Hemolytic Explanation: Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A A slightly enlarged liver with palpably hard edges B A nonpalpable liver C A slightly decreased size of the liver D Similar liver size and texture as in younger adults

A slightly decreased size of the liver Explanation: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges.

The burned client on admission is drooling and having difficulty swallowing. What is the nurse's best first action? Assess level of consciousness and pupillary reactions. Ask the client at what time food or liquid was last consumed Auscultate breath sounds over the trachea and mainstem bronchi Measure abdominal girth and auscultate bowel sounds in all four quadrants

Auscultate breath sounds over the trachea and mainstem bronchi Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client's airway is in severe jeopardy and intubation is highly likely to be needed shortly.

A client is diagnosed with posttraumatic stress disorder (PTSD). Which finding would the nurse most likely assess? Constricted pupils Muscle flaccidity Bradycardia Diaphoresis

Diaphoresis Explanation: With posttraumatic stress disorder (PTSD), the client may exhibit diaphoresis with cold, clammy skin, dilated pupils, tachycardia or palpitations, and muscle tension. These physiologic findings are related to increased sympathetic nervous system activity, increased plasma catecholamine levels, and increased urinary epinephrine and norepinephrine levels.

A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A Performing meticulous hand hygiene at the appropriate moments in care B Wearing an N95 mask when providing care for patients on airborne precautions C Disposing of sharps appropriately and not recapping needles D Adhering to the recommended schedule of immunizations

Disposing of sharps appropriately and not recapping needles Explanation: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? Explain to the client that care is going to be provided because he is seriously ill. Document the client's condition and absence of friends or family for obtaining consent to treatment. Ask the ambulance team for information about the client's family to ensure informed consent. Check the client's record for the name of a family member to call to allow care to be provided.

Document the client's condition and absence of friends or family for obtaining consent to treatment. Explanation: Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.

At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? Immediately following the injury During the fluid shift During fluid remobilization During the late acute phase

During fluid remobilization Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output.

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? Emergent Immediate Urgent Nonacute

Emergent Explanation: The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to non-acute, non-life-threatening injury or illness.

A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next? A Encourage the patient to cough forcefully. B Insert a nasopharyngeal airway. C Prepare the patient for a bronchoscopy. D Insert an oropharyngeal airway.

Encourage the patient to cough forcefully. Explanation: If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The patient is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction. If the person is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.

A nurse is performing a primary survey of a client brought to the emergency department. Which of the following would the nurse include? Select all that apply. Applying monitoring devices Providing adequate ventilation Obtaining a complete health history Assessing neurologic function Establishing airway patency

Establishing airway patency Providing adequate ventilation Assessing neurologic function Explanation: The primary survey addresses airway, breathing, circulation, and disability. The nurse would establish a patent airway, provide adequate ventilation, evaluate and restore cardiac output, and determine neurologic disability by assessing neurologic function. Obtaining a complete health history and applying monitoring devices are activities involved with the secondary survey.

Which type of deficiency results in macrocytic anemia? A Folic acid B Vitamin A C Vitamin K D Vitamin C

Folic acid Explanation: Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A Wearing a condom during sexual contact B Following proper hand-washing techniques C Limiting alcohol intake D Avoiding chemicals that are toxic to the liver

Following proper hand-washing techniques Explanation: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measures is indicated.

A 57-year-old firefighter was severely burned fighting a house fire. During his aggressive treatment, the client begins to exhibit symptoms of renal failure. What physiologic process can cause acute renal failure? A Hemoconcentration B Anemia C Histamine D Fluid, electrolyte status

Hemoconcentration Explanation: The client with a burn experiences hemoconcentration when the plasma component of blood is lost or trapped. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure.

A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions? A Asterixis B Cirrhosis C Portal hypertension D Hepatic encephalopathy

Hepatic encephalopathy Explanation: Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction. Cirrhosis is a chronic liver disorder characterized by fibrotic changes, the formation of dense connective tissue within the liver, subsequent degenerative changes, and loss of functional liver tissue.

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? Large intestine Kidneys Liver Stomach

Liver Explanation: Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ. Thus, of the options shown, the nurse would assess the liver area most closely.

A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? A Lobectomy B IV administration of immune globulins C Transfusion of packed red blood cells and fresh-frozen plasma (FFP) D Liver transplantation

Liver transplantation Explanation: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? Maintain a diet for the client that is high in protein, vitamins, and calories. Avoid range of motion exercises for the client because of spasms. Keep accurate intake and output. Watch closely for signs of urinary tract infection.

Maintain a diet for the client that is high in protein, vitamins, and calories. Explanation: To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

Which type of débridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? A Natural B Mechanical C Surgical D Chemical

Mechanical Explanation: Mechanical débridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic débridement agents are available to promote débridement of the burn wounds. With natural débridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical débridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tissue.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? Avoidance of all lotions and lubricants Meticulous cleanliness Continuous use of an indwelling catheter Allowing the client to choose the position of comfort

Meticulous cleanliness Explanation: Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.

Which of the following is the most common cause of spinal cord injury (SCI)? Acts of violence Falls Sports-related injuries Motor vehicle crashes

Motor vehicle crashes Explanation: The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI.

The nurse is caring for a patient with deep partial-thickness burn injuries. Which of the following statements reflect current research regarding the utilization of nonpharmacological measures in the management of burn pain? A Music therapy diverts the patient's attention toward painful stimulus. B Pet therapy has proven effective in the management of burn pain. C Music therapy may provide reality orientation, distraction, and sensory stimulation. D Humor therapy has not proven effective in the management of burn pain.

Music therapy may provide reality orientation, distraction, and sensory stimulation. Explanation: Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the patient's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It also allows for patient 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.

The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action? Raise the head of the bed. Notify the emergency team. Loosen the dressings on the chest. Document the findings as the only action.

Notify the emergency team. Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway and the swelling usually precludes intubation.

A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen? Abdominal distention Pain in the left shoulder Rebound abdominal tenderness Contusion of the right upper quadrant

Pain in the left shoulder Explanation: Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen. Pain in the right shoulder is consistent with a laceration of the liver. The spleen is located in the left upper quadrant, not the right. Rebound tenderness and abdominal distention are generalized signs suggesting intraperitoneal injury. Although these generalized signs may accompany a ruptured spleen, they are less specific than pain in the left shoulder.

A patient with a burn wound is prescribed mafenide acetate 5% (Sulfamylon) twice daily. Nursing implications associated with this medication include which of the following? A Monitoring the patient for the development of respiratory acidosis B Premedicating the patient with an analgesic prior to application C Monitoring the patient's Na+ and K+ serum levels and replace as prescribed D Protecting the bed linens and patient's clothing from contact to prevent staining

Premedicating the patient with an analgesic prior to application Explanation: Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the patient is an appropriate intervention. The other nursing implications are not associated with mafenide.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? Protecting himself or herself Securing the area Gaining control of the situation Providing care to the injured

Protecting himself or herself Explanation: If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.

Following a burn injury, which of the following areas is the priority for nursing assessment? A Nutrition B Cardiovascular system C Pulmonary system D Pain

Pulmonary system Explanation: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? A Sodium excess B Increased urinary output C Reduction in blood volume D Potassium deficit

Reduction in blood volume Explanation: A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A Ensure that the patient's sodium intake does not exceed recommended levels. B Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. C Implement interventions aimed at ensuring a calm and therapeutic care environment. D Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.

Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. Explanation: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patient's physiologic deterioration.

The nurse is participating in a health fair about fire safety. Which of the following interventions helps to minimize the risk of further injury to an affected person at a scene of a fire when clothes catch fire? A Cover the patient with a wet cloth. B Roll the patient in a blanket. C Place the patient with the head positioned slightly below the rest of the body. D Avoid immediate IV fluid therapy.

Roll the patient in a blanket. Explanation: 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 patient 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.

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency? A Hypoprothrombinemia B Beriberi C Scurvy D Night blindness

Scurvy Explanation: Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.

Which of the following terms refers to muscular hypertonicity with increased resistance to stretch? Myoclonus Akathisia Ataxia Spasticity

Spasticity Explanation: Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to a restless, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

The nurse is caring for a patient immediately following a spinal cord injury (SCI). Which of the following is an acute complication of spinal cord injury? Spinal shock Tetraplegia Cardiogenic shock Paraplegia

Spinal shock Explanation: Acute complications of SCI include spinal and neurogenic shock and deep-vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury.

Following a motor vehicle collision, a patient is brought to the ED for evaluation and treatment. The patient is being assessed for intra-abdominal injuries. The patient states severe left shoulder pain (pain score of 10 on a 1 to 10 pain scale). The nurse suspects injury to which of the following? Large intestines Gallbladder Spleen Liver

Spleen Explanation: The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Laceration Avulsion Stab Patterned

Stab Explanation: A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.

A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider? A Bradycardia and tachypnea B Tachycardia and tachypnea C Bradycardia and bradypnea D Tachycardia and bradypnea

Tachycardia and tachypnea Explanation: With shock, the sympathetic nervous system (SNS) is activated due to changes in blood volume and blood pressure. The SNS stimulates the cardiovascular system, causing tachycardia, and the respiratory system, causing tachypnea. Tachycardia is associated with shock, but the patient will have tachypnea, not bradypnea. Tachycardia (not bradycardia) and tachypnea (not bradypnea) occur with the compensatory stage of shock. Although tachypnea is associated with shock, tachycardia, not bradycardia, occurs with shock.

The nurse is caring for a patient with superficial partial-thickness burn injuries to the lower extremities. The patient is ordered IV morphine for pain. The nurse understands narcotics are given IV to manage pain during the initial management of pain because of which of the following? A Tissue edema may interfere with drug absorption via other routes. B The patient can experience nausea and emesis when given oral medications. C Pain resulting from a burn injury requires relief by the fastest route available. D Bleeding may occur at injection sites when the intramuscular route is used.

Tissue edema may interfere with drug absorption via other routes. Explanation: IV administration is necessary because of altered tissue perfusion from the burn injury.

A finger sweep is only to be used in which patient population? Conscious adult Child Unconscious adult Adolescent

Unconscious adult Explanation: A finger sweep should be used only in the unconscious adult patient. This action draws the tongue away from the back of the throat and away from the foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent.

Which type of positioning should be utilized for a patient undergoing a paracentesis? a Supine b Prone c Trendelenburg d Upright at the edge of the bed

Upright at the edge of the bed Explanation: The patient should be placed in an upright position on the edge of the bed or in a chair with the feet supported on a stool. Fowler's position should be used by the patient confined to bed.

A patient presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the patient into which of the following categories? Psychological support Emergent Nonurgent Urgent

Urgent Explanation: Patients triaged have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for patients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for patients who have episodic illness that can be addressed within 24 hours without increased morbidity. Patients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? A Thiamine B Vitamin K C Riboflavin D Vitamin A

Vitamin A Explanation: Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

Which of the following indicates an overdose of lactulose? A Hypoactive bowel sounds B Watery diarrhea C Constipation D Fecal impaction

Watery diarrhea Explanation: The patient receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

The nurse is caring for a 30-year-old female patient who suffered severe head and facial burn injuries. Which of the following actions, if completed by the patient, indicates she is adapting to her altered body image? Select all that apply. A Participates actively in daily activities B Covers her face with a scarf C Reports absence of sleep disturbance D Wears hats and wigs

Wears hats and wigs Participates actively in daily activities Explanation: The following are indicators that a patient is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the patient is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured patient but is not related to body image disturbance.

The client, who is a veteran and has posttraumatic stress disorder, tells the nurse about the horror and mass destruction of war. He states, "I killed all of those people for nothing." Which response by the nurse is appropriate? "You did what you had to do at that time." "Maybe you did not kill as many people as you think." "How many people did you kill?" "War is a terrible thing."

You did what you had to do at that time." Explanation: The nurse states, "You did what you had to do at that time," to help the client evaluate past behavior in the context of the trauma. Clients commonly feel guilty about past behaviors when viewing them in the context of current values. The other statements are inappropriate because they do not help the client to evaluate past behavior in the context of the trauma.