Test 6
10. A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how she can assist. The best response by a nurse working for the trauma center would be to: a. assign the nurse administrative duties, such as obtaining patient demographic information. b. assign the nurse to a triage room with another nurse from the emergency department. c. thank the nurse but inform her to return to her department as her skill set is not a good match for patients needs. d. have the nurse assist with transport of patients to procedural areas.
ANS: A A nurse in the medical records department is most likely familiar with the disaster plan and although she doesnt currently provide direct care to patients, she is a knowledgeable healthcare provider who can help in a disaster by obtaining essential patient information. Assigning the nurse to provide direct care to patients, such as assisting in the triage room or transporting patients, may not be appropriate, as the direct care skills are not known. Asking the nurse to return to her department also may not be appropriate because the nurse offers a skill set that can be used during the disaster.
16. The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to: a. remove the patients clothes and flush the area with water. b. apply saline compresses. c. contact a poison control center for directions on neutralizing agents. d. remove all jewelry.
ANS: A As long as the chemical remains in contact with the skin, burn damage will result. Priority interventions are to remove the patients clothes, brush loose chemical away from the skin and apply water for at least 30 minutes. Water needs to washed away from the body, not be applied as compresses. Contacting poison control may be helpful in obtaining more information on the systemic effects of the chemical, but it is not a priority intervention. Jewelry should be removed, but this is not as high a priority as removing the chemical and stopping the chemical burning process through continuous flushing with water.
3. An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a. Level I b. Level II c. Level III d. Level IV
ANS: A Because the patient is hypotensive and was unrestrained, the patient is at higher risk for more severe injuries related to the mechanism of injury; thus, treatment should occur at a level I trauma center. Patients with less severe injuries can be treated at lower level trauma centers.
19. Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a. 30 mL/hr. b. 50 mL/hr. c. 100 mL/hr. d. 300 mL/hr.
ANS: C Treatment of rhabdomyolysis consists of aggressive fluid resuscitation to flush the myoglobin from the renal tubules. A common protocol includes the titration of IV fluids to achieve a urine output of 100 to 200 mL/hr. Urine volumes less than 100 mL/hr are insufficient and a urine volume greater than 200mL/hr will not harm the patient but may create too aggressive a diuresis.
8. The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a. Placement of an intraosseous catheter b. Placement of a central line placement c. Insertion of a femoral catheter by a trauma surgeon d. Rapid transfer to the operating room
ANS: A Infusion of volume is required for optimal fluid resuscitation and may be achieved through large caliber venous cannulation or intraosseous access. A central line or femoral vein access may be obtained by the physician, but the procedure requires time. Transport to the operating room is not a priority in the goal to obtain intravenous access for fluid resuscitation.
8. The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a. Central nervous system deficits b. Contractures c. Infection d. Stress ulcers
ANS: A Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits. Contractures, infection, and stress ulcer risks are no greater than with other causes of burn injury.
7. Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture? a. Insertion of a nasogastric tube b. Insertion of an indwelling urinary catheter c. Endotracheal intubation d. Placement of an oral airway
ANS: A Nasogastric tubes are contraindicated in basilar skull fractures because insertion may result in penetration of the meninges. An indwelling urinary catheter may be necessary to monitor fluid balance. Protection of the airway to include placement of an oral airway or endotracheal tube may be indicated.
23. A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible nonburn injured skin disorder? a. Toxic epidermal necrolysis b. Staphylococcal scalded skin syndrome c. Necrotizing soft tissue infection d. Graft versus host disease
ANS: A Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present with acute onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours, skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury. Staphylococcal scalded skin syndrome presents predominantly in children. Necrotizing soft tissue infection results from rapidly invasive bacterial infections. Graft versus host disease is not logical given the clinical information provided.
2. Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also due to the patients long-term management. Which of the following statements apply to trauma patients? (Select all that apply.) a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection.
ANS: A, B, C Prevention of infection is essential in the care of trauma and postsurgical patients. Removing invasive devices when they are no longer needed for monitoring and ensuring aseptic care of devices are important nursing care considerations for management of indwelling urinary catheters, central lines, and airway adjuncts. Wounds, other than the immediate postoperative dressing, are not required to be sterile. Aseptic technique is used for wound care.
1. Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration.
ANS: A, B, C The rapid metabolism associated with burn injury may require additional pain medication. Many of the procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication should be given prior to the procedures. Edema in burned patients alters the absorption of medications that are injected intramuscularly; therefore, drugs must be administered by the IV route.
6. An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.) a. involves a joint. b. involves the face, hands, or feet. c. is infected. d. requires more than 2 weeks for healing
ANS: A, B, D Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization.
7. Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered c. Administration of potassium as ordered d. Administration of calcium as ordered
ANS: A, B, D Ineffective coagulation is a serious complication for a trauma patient that can be prevented by maintaining normothermia, evaluating and treating for hypocalcemia, administering clotting factors found in fresh frozen plasma or platelets, and evaluating and treating metabolic acidosis. Evaluating and treating serum potassium levels is important for effective cardiac muscle function, not coagulation.
3. The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages
ANS: A, B, D It is important to avoid immobility in patients with burns of the hands, feet, or major joints. Measures must be taken to maintain the function of the hands, feet, and major joints. Nursing interventions to maintain range of motion, applying splits to keep the extremities in a position of function, and individually wrapping fingers and toes are necessary to maintain function of the hands, feet, and joints. Effective pain management is necessary to encourage mobility.
6. Which interventions can the nurse implement to assist the patients family in coping with the traumatic event? (Select all that apply.) a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. c. Limit visitation to set times throughout the day. d. Coordinate a family conference.
ANS: A, B, D The trauma team can assist the patient and family in crisis by helping them establish a consistent communication process between the healthcare team and family. Other interventions include exploring the familys perceptions of the event, support systems, and coping mechanisms. Family conferences early in the emergent phase and frequently during the critical care phase assist with communication and with understanding the patients and familys expectations for care. Limiting visitation will not assist the patient or the familys ability to cope with the traumatic event.
5. Which complications may manifest after an electrical injury? (Select all that apply.) a. Long bone fractures b. Cardiac dysrhythmias c. Hypertension d. Compartment syndrome of extremities e. Dark brown urine f. Peptic ulcer disease g. Acute cataract formation h. Seizures
ANS: A, B, D, E, G, H Electrical injuries vary in severity of injury by the intensity of energy exposed to the body. Manifestations and complications may include cardiac dysrhythmias or cardiopulmonary arrest, hypoxia, deep tissue necrosis, rhabdomyolysis and acute kidney injury, compartment syndrome, long bone fractures, acute cataract formation, and neurological deficits (including seizures). Hypertension and peptic ulcer disease are not direct consequences of electrical burn injuries.
5. Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a. Crush injury to right arm b. Gunshot wound to the abdomen c. Lightning strike of the left arm and chest d. Pulmonary contusion and rib fracture
ANS: A, C Causes of rhabdomyolysis include crush injuries, compartment syndrome, burns, and injuries from being struck by lightning. Acute kidney injury may result from a gunshot wound related to prolonged hypotension. Acute kidney injury would not have a direct cause associated with a pulmonary contusion.
3. During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurses suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air
ANS: A, C, D Pulmonary contusion is a serious injury associated with deceleration or blast forces and is a common cause of death after chest trauma. The clinical presentation includes chest wall abrasions, ecchymosis, bloody secretions, and a partial pressure of arterial oxygen (PaO2) of less than 60 mm Hg while breathing room air. The bruised lung tissue becomes edematous, resulting in hypoxia and respiratory distress. Absence of breath sounds is more suggestive of atelectasis or a collapsed lung.
8. Which of the following findings require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury? (Select all that apply.) a. Mean arterial pressure 48 mm Hg b. Elevated serum blood alcohol level c. Non-reactive pupils d. Respiratory rate of 10 breaths per minute
ANS: A, C, D Rapid assessment of patients with neurological injury is vital to the treatment of patients with traumatic brain injury. Preventing hypotension (mean arterial pressure less than 50 mm Hg) is essential to maintain cerebral perfusion; non-reactive pupils are an abnormal finding and require immediate attention to evaluate the cause. Adequate oxygenation and ventilation are necessary to deliver oxygen to the brain; thus, a respiratory rate of 10 requires further evaluation. An elevated blood alcohol level interferes with the ability to conduct a neurological examination but does not require immediate intervention.
4. Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management.
ANS: A, C, E Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and restricting family is not an intervention related to infection prevention.
17. Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied? a. Arm b. Face c. Leg d. Chest
ANS: B A sheet graft is more likely to be used on the face and hands because the cosmetic effects are more optimal. Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg, chest, etc.).
7. A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to: a. excessive alcohol use. b. methamphetamine use. c. posttraumatic stress disorder. d. subacute delirium.
ANS: B A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury.
20. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for: a. acute delirium. b. posttraumatic stress disorder. c. suicidal intentions. d. bipolar disorder.
ANS: B Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients that demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder. Acute delirium is more likely to occur during the acute phase of injury. Suicidal ideations should always be addressed if the patient expresses or shows signs of suicidal thoughts. Burn-injured patients may have an underlying mental health disorder that requires treatment, such as bipolar disorder or schizophrenia.
18. The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is: a. altered nutrition, less than body requirements. b. body image disturbance. c. decreased cardiac output. d. fluid volume deficit.
ANS: B Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result. Nutritional support is started early in management of the patient with burns, and there is no indication that this patient has a nutritional deficit. Nursing care plan priorities would also continue to focus on nutritional needs to optimize healing. Decreased cardiac output and fluid volume deficit should not be priority concerns during the wound closure phase of burn wound management by grafting.
21. A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? a. Blood pressure 82/60, heart rate 122, respiratory rate 28. b. Crackles (rales) on auscultation of bilateral lung fields. c. Responsive only to painful stimuli. d. Irregular heart rate and rhythm.
ANS: B Explosive blast energy generates shock waves that create changes in air pressure, causing tissue damage. Initially after an explosion, there is a rapid increase in positive pressure for a short period, followed by a longer period of negative pressure. The increase in positive pressure injures gas-containing organs. The tympanic membrane ruptures, and the lungs may show evidence of contusion, acute edema, or rupture. A low blood pressure and corresponding tachycardia is more suggestive of hypovolemia. Lack of response to stimuli suggests a neurological injury. An irregular heart rate and rhythm may be associated with blunt trauma to the heart (e.g. cardiac contusion).
12. An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was too hot and that the patient sat in the water too long. What should the nurse do? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patients burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred.
ANS: B In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver. While obtaining safety information on the temperature of the water heater is important, it is not a priority assessment question. The nurse should follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may include contacting the police or social services. Asking the caregiver to describe how the injury occurred is important (e.g., there may be discrepancies in the physical assessment and reported mechanism of burn injury); however, examining the patient away from the caregiver is a priority.
10. When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a. Carbon monoxide poisoning always occurs when soot is visible. b. Inhalation injury above the glottis may cause significant edema that obstructs the airway. c. The patient will have a copious amount of mucus that will need to be suctioned. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.
ANS: B In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation.
14. The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following? a. Maintain a closed wound system to decrease the risk of infection. b. Remove excessive wound fluid and promote moist wound healing. c. Increase patient mobility with large burn wounds. d. Quantify wound drainage amount for more accurate output assessment.
ANS: B Negative-pressure wound therapy can be used to treat grafts or partial-thickness burns by decompressing edematous interstitial spaces that enhance local perfusion, optimizing wound healing. This therapy also provides a moist wound-healing environment. The system is closed and may reduce the risk of infection but may not prevent infection. Patients are less mobile because the system needs an electrical source to function. Wound drainage is quantified by using the negative-pressure wound therapy system, but this is not a primary indication for the therapy.
19. The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurses knowledge of nutritional goals? a. Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal. b. Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal. c. It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster. d. Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing.
ANS: B Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body.
16. During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent: a. disseminated intravascular coagulation. b. multisystem organ dysfunction. c. septic shock. d. wound infection.
ANS: B Patients with multisystem injuries are at high risk of developing myriad complications associated with the overwhelming stressors of the injury, prolonged immobility, and consequences of inadequate tissue perfusion and oxygenation. Maintaining effective tissue perfusion, oxygenation, and nutritional support are all vital to prevent progression into multiple organ dysfunction syndrome. Disseminated intravascular coagulation, septic shock, and wound infections are best prevented by addressing infection early and aggressively with appropriate antibiotics and nursing interventions to reduce infection (e.g. hand hygiene).
2. When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident? a. High-speed motor vehicle crashes b. Poisonings from prescription or illegal drugs c. Violent or domestic traumatic altercations d. Work-related falls
ANS: B People age 35 to 54 years are at greater risk of experiencing poisonings from prescription and/or illegal drugs resulting in unintentional injury, followed by motor vehicle crashes (MVCs). MVCs and homicide are the leading causes of death for individuals age 16 to 24 years, and falls are responsible for traumatic injuries in the 65 years and older population. Domestic violence is not well defined as an age-related trauma incident.
17. Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent: a. catheter-associated infection. b. venous thromboembolism. c. fat embolism. d. nosocomial pneumonia.
ANS: B Prevention of venous thromboembolism is essential in the management of trauma patients. If not medically contraindicated, patients should receive pharmacological prophylaxis (e.g. heparin or heparin derivatives). Nurses should encourage ambulation, evaluate the patients overall hydration, and ensure sequential compression devices are used properly. Prevention of catheter-associated infections is also important through interventions that maintain the integrity of the catheter site and injection ports. Hydration and ambulation, along with pulmonary exercises, help prevent pneumonia. Fat embolism is associated with long bone fractures and early recognition of this complication is essential to treatment.
13. Silver is used as an ingredient in many burn dressings because it: a. stimulates tissue granulation. b. is effective against a wide spectrum of wound pathogens. c. provides topical pain relief. d. stimulates wound healing.
ANS: B Silver is an ingredient in many dressings because it helps prevent infection against a wide spectrum of common pathogens. Silver does not stimulate tissue granulation; nor does it provide pain relief or stimulate wound healing processes.
5. The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is : a. Keeping the extremity in a dependent position b. Active and passive range of motion every hour. c. Preparing for an escharotomy as a prophylactic measure d. Splinting the forearm
ANS: B Special attention is given to circumferential (completely surrounding a body part) full thickness burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema. Peripheral pulses are assessed every hour, especially in circumferential burns of the extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome are present on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation.
4. Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a. A fall from a 6-foot ladder onto the grass b. A shotgun wound to the abdomen c. A knife wound to the right chest d. A motor vehicle crash in which the driver hits the steering wheel
ANS: B The penetrating injury of the gunshot wound would cause the greatest amount of injury because of the kinetic energy and dispersion pattern of the shotgun ammunition once it penetrated the body. A fall would cause a compression injury from the blunt force of the fall. The knife wound would cause a penetrating injury in which the magnitude of the injury would depend on damage to the vessels and lung. Blunt chest trauma that may include a cardiac contusion is possible following an injury in which the patient hits the steering column.
24. A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a. chemical burn b. electrical burn c. heat burn d. infection
ANS: B Tissue damage results from the conversion of electrical energy into heat. Monitor the patient for cardiac dysrhythmias.
20. Which of the following statements about mass casualty triage during a disaster is true? a. Priority treatments and interventions focus primarily on young victims. b. Disaster victims with the greatest chances for survival receive priority for treatment. c. Once interventions have been initiated, healthcare providers cannot stop the treatment of disaster victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.
ANS: B Victims are triaged based on the severity of injury. Patients receive treatment based on the assessment of greatest chances for survival matched to resources available for medical intervention. Age is not a determination in rendering interventions. Patient survival and severity of injury are the priority assessment for triage. If interventions are initiated and found to be ineffective, treatment can be stopped according to principles of ethical care. Color-coded systems are frequently used during disasters to signify patients in greatest need of assistance, with red indicating worse severity of injury and green being most stable.
1. Fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully cross-matched blood products are administered.
ANS: B, C Lactated Ringers and normal saline are the crystalloids of choice in trauma resuscitation. Because hypothermia is a concern, fluids should be warmed. Massive blood transfusions are associated with poor outcomes. Cross-matched blood is preferred, but blood type O, universal donor blood, can be administered in an emergency. DIF: Cognitive Level: Analysis REF: p. 594
4. It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. ARDS b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction
ANS: B, C, D Prolonged hypothermia is associated with the development of myocardial dysfunction, coagulopathies, reduced perfusion, and dysrhythmias (bradycardia and atrial or ventricular fibrillation). ARDS is a complication associated with excessive inflammation and over-resuscitation.
2. Which of the following factors increase the burn patients risk for venous thromboembolism? (Select all that apply.) a. Burn injury less than 10% b. Bedrest c. Burns to lower extremities d. Electrical burn injury e. Delayed fluid resuscitation
ANS: B, C, E Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bedrest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA.
4. The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a. 2800 mL b. 7000 mL c. 14 L d. 28 L
ANS: C 154 pounds/2.2 = 70 kg 4 70 kg 50 = 14,000 mL, or 14 liters.
2. In patients with extensive burns, edema occurs in both burned and unburned areas because of: a. catecholamine-induced vasoconstriction. b. decreased glomerular filtration. c. increased capillary permeability. d. loss of integument barrier.
ANS: C Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third spacing). Catecholamine-induced vasoconstriction does not produce edema. Decreased glomerular filtration may cause fluid retention, but it is not responsible for the extensive edema seen after burn injury. Loss of integument barrier does not cause edema.
1. The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is: a. blood urea nitrogen. b. daily weight. c. hourly intake and urine output. d. serum potassium.
ANS: C During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone. Blood urea nitrogen may be used to monitor volume status, but it is affected by the hypermetabolic state seen after burns, so it is not the optimal measure of intravascular fluid status. Daily weight measures overall volume status, not just intravascular volume. Serum potassium is released with tissue damage and thus is not the optimum measure of intravascular fluid status.
14. Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a. A patient who has a closed head injury with a decreased level of consciousness b. A patient who has a fractured femur and is currently in traction c. A patient who has received large volumes of fluid and/or blood replacement d. A patient who has underlying chronic obstructive pulmonary disease
ANS: C During states of hypoperfusion and acidosis, inflammation occurs and vessels become more permeable to fluid and molecules. With aggressive fluid resuscitation, this change in permeability allows the movement of fluid from the intravascular space into the interstitial spaces (third spacing). As more IV fluids are given to support systemic circulation, fluids continue to migrate into the interstitial space, causing excessive edema and predisposing the patient to additional complications such as abdominal compartment syndrome, ARDS, acute kidney injury, and MODS. A patient with a closed head injury, a patient with a fractured femur stabilized by traction, and a patient with chronic obstructive pulmonary disease may develop ARDS, but it would be related to fluid resuscitation and excessive inflammation associated with traumatic injury.
9. In the trauma patient, symptoms of decreased cardiac output are most commonly caused by: a. cardiac contusion. b. cardiogenic shock. c. hypovolemia. d. pericardial tamponade.
ANS: C Hypovolemia is commonly associated with traumatic injury resulting from acute blood loss. Cardiac contusion may decrease cardiac output, but hypovolemia occurs more often. Cardiogenic shock is not typically associated with trauma. Pericardial tamponade would decrease cardiac output but is not as common as hypovolemia.
11. A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for: a. acute kidney injury. b. acute respiratory distress syndrome. c. intraabdominal hypertension. d. disseminated intravascular coagulation disorder.
ANS: C Intraabdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function. Acute kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen. Disseminated intravascular disorder may present as a tense abdomen if there is active bleeding, but it would not present with pulmonary symptoms.
1. Which of the following best defines the term traumatic injury? a. All trauma patients can be successfully rehabilitated. b. Traumatic injuries cause more deaths than heart disease and cancer. c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d. Trauma mainly affects the older adult population.
ANS: C Many patients who sustain traumatic injury are under the influence of alcohol, drugs, or other substances. Rehabilitation potential depends on multiple factors including severity of injury, patient age, and comorbidities. Heart disease and cancer claim more lives than trauma, but trauma claims lives of predominantly young individuals.
22. The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a. Do you live alone? b. Do you have any drug or food allergies? c. Do you have a heart condition or heart failure? d. Have you had any surgeries?
ANS: C Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutrition status, and comorbid diseases, especially heart failure. Assessment questions should include, as a priority, information about the patients cardiovascular status, including heart failure. Obtaining food or drug allergy information is also important along with other past medical history, including past surgeries. Information on the patients living arrangements is an important safety consideration for discharge planning.
11. A near-infrared spectroscopy (NIRS) probe is placed in a trauma patient during the resuscitation phase to: a. assess severity of metabolic acidosis. b. determine intraperitoneal bleeding. c. determine tissue oxygenation. d. prevent complications of over-resuscitation.
ANS: C NIRS is a continuous noninvasive technology that uses principles of light transmission to measure skeletal muscle oxygenation as an indicator of shock. Low oxygenation levels detected by NIRS may suggest metabolic acidosis but requires laboratory analysis. Poor tissue perfusion determined through NIRS requires further evaluation of causes of shock, including intraperitoneal bleeding. NIRS would not be helpful in determining complications associated with over-resuscitation.
6. The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate? a. Insert an oral airway to prevent aspiration and to protect the airway. b. Offer the patient an emesis basin so that you can measure the amount of emesis. c. Prepare to suction the oropharynx while maintaining cervical spine immobilization. d. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.
ANS: C Stabilization of the cervical spine, preventing aspiration, and maintaining a patent airway are essential elements of trauma management. An oral airway may increase the risk of aspiration related to the emesis and offering an emesis basin would contradict spine precautions. Alcohol level is best determined by serum analysis.
6. The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurses best response would be: a. Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound. b. An autograft is a biological dressing that will eventually be replaced by your body generating new tissue. c. Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound. d. Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound.
ANS: C The autograft is the only permanent method of grafting and it uses the patients own tissue to cover the burn wound. Autografting is permanent and does not require a second surgery unless the graft fails. A biological or biosynthetic graft or dressing is a temporary wound covering. A xenograft is from an animal, usually pig skin and is a temporary graft.
3. Tissue damage from burn injury activates an inflammatory response that increases the patients risk for: a. acute kidney injury. b. acute respiratory distress syndrome. c. infection. d. stress ulcers.
ANS: C The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection. A systemic inflammatory response (SIRS) also increases the risk of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of stress ulcers.
5. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED: a. includes a cervical spine x-ray study to determine the presence of a fracture. b. involves turning the patient from side to side to get a look at his back. c. is done quickly in the first few minutes to get a baseline assessment and establish priorities. d. is a methodical head-to-toe assessment identifying injuries and treatment priorities.
ANS: C The primary survey is a systematic rapid assessment of the patients airway with cervical spine immobilization, breathing and ventilation, circulation with hemorrhage control, disability or neurological status, and exposure/environmental considerations. The secondary survey is more methodical and involves identifying injuries and specific treatment priorities.
9. The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because: a. intramuscular injections cause additional skin disruption. b. burn pain is so severe it requires relief by the fastest route available. c. hypermetabolism limits effectiveness of medications administered intramuscularly. d. tissue edema may interfere with drug absorption of injectable routes.
ANS: D Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly. Even though it is true intramuscular injections disrupt tissue, medication absorption is not effective. Burn pain is severe and intravenous administration is desired to relieve pain, but this is not the physiological basis for giving medications intravenously. Hypermetabolism affects medication effectiveness but is not the rationale for administering opioids intravenously.
15. The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to: a. hypervolemia from burn resuscitation. b. increased incidence of ureteral stones. c. nephrotoxic antibiotics for prevention of infection. d. release of myoglobin from injured tissues.
ANS: D Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and acute kidney injury. Hypervolemia is not a cause of acute kidney injury. Ureteral stones and nephrotoxic antibiotics may cause acute kidney injury but is not associated with the electrical injury.
21. The nurse is planning care to meet the patients pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurses knowledge of pain management for this patient? a. Can we ask the music therapist to come by each morning to see if that will help the patients pain? b. The patients pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock. c. The patients pain is often unrelieved. It would be best if we can schedule the opioids around the clock. d. The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?
ANS: D Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing independence with pain management strategies. Nonpharmacological pain strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put the control of pain management with the patient.
15. Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a. Absence of pulse in affected extremity b. Pallor in the affected area c. Paresthesia in the affected area d. Severe, throbbing pain in the affected area
ANS: D Patients with compartment syndrome complain of increasing throbbing pain disproportionate to the injury. Narcotic administration does not relieve the pain. The pain is localized to the involved compartment and increases with passive muscle stretching. The area affected is firm. Paresthesia distal to the compartment, pulselessness, pallor, and paralysis are late signs and must be reported immediately to prevent loss of the extremity.
12. The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels
ANS: D Serum lactate levels are useful in assessing acidosis and the need for aggressive fluid resuscitation. Arterial oxygen saturation provides clinical information on oxygen delivery to cells. Hourly urine output and mean arterial pressure provide information on systemic perfusion and are monitored in the assessment of effective resuscitation; however, serum lactate is a better indicator of metabolic acidosis caused by under-perfusion (under-resuscitation).
18. Which of the following interventions is a strategy to prevent fat embolism syndrome? a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with lowmolecular weight heparin. d. Stabilize extremity fractures early.
ANS: D Stabilization of extremity fractures to minimize both bone movement and the release of fatty products from the bone marrow must be accomplished as early as possible. Administration of statin medications has no effect on prevention of fat embolism. Intubation and mechanical ventilation may be necessary to support the pulmonary system in the event the patient has a fat embolism, but it will not prevent this complication. Heparin will not prevent fat embolism; it is for venous thromboembolism prophylaxis.
13. The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of his car. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurses assessment, the oxygen saturation drops to 80%. The patients blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates: a. administration of lactated Ringers solution (1 L) wide open. b. chest x-ray study to determine the etiology of the symptoms. c. endotracheal intubation and mechanical ventilation. d. needle thoracostomy and chest tube insertion.
ANS: D These are classic symptoms of a tension pneumothorax in a patient at high risk related to mechanism of injury. Emergent decompression by a needle thoracostomy followed by a chest tube insertion is needed. A chest x-ray would delay treatment and is not needed prior to emergent intervention. Administration of IV fluids would not assist with blood pressure, as increased thoracic pressure from the tension pneumothorax needs to be relieved to restore cardiac output (and blood pressure). Endotracheal intubation and mechanical ventilation may be necessary after the tension pneumothorax is relieved to assist with the patients ventilation.
1. The correct order of actions in the management of the postoperative surgical trauma patient who has been admitted to the critical care unit after surgery is: _______________, _______________, _______________,_______________. (Put a comma and space between each answer choice.) a. Connect the patient to bedside monitor and mechanical ventilator. b. Obtain vital signs, rhythm, oxygen saturation, and neurological status. c. Assess airway, breathing, and circulation. d. Reassess and evaluate patency of IV lines, and adjust rate of fluid administration as ordered.
C, A, B, D The initial intervention upon admission to the critical care unit is a rapid assessment of airway, breathing, and circulation. The nurse quickly connects the patient to the bedside monitor and ventilator, and completes an assessment of vital signs, cardiac rhythm, pulse oximetry reading, level of consciousness, and pupil reactivity. The nurse reassesses IV access and evaluates the patency of IV catheters, because they may have become dislodged during transport. Calculation of medication dosages and rates is completed as part of the initial assessment. Once the assessment and initial interventions have been completed, the family is contacted to see the patient.
1. The correct priority order of actions in prehospital primary survey for burn injuries is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.) a. Assess ABCs and cervical spine. b. Provide oxygen therapy if smoke inhalation is suspected. c. Make rapid head-to-toe assessment to rule out additional trauma. d. Stop the burning process and prevent further injury.
D, A, B, C Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries.
2. Prevention of hypothermia is crucial in caring for trauma patients. The correct order of actions for the preparation for the trauma patient is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.) a. Remove wet clothing. b. Warm fluids and blood products before administration. c. Cover the patient with an external warming device. d. Warm the ED or intensive care unit (ICU) room before the patients arrival.
D, A, C, B Before arrival to the ED or ICU, the receiving room needs to be warmed. The patients clothing is removed, and he or she should be covered to prevent external loss of heat. An external warming device needs to be immediately available for warming the patient after arrival. Fluids that are administered should be warmed via active internal devices.
