Trauma and burns practice questions
A client is admitted to the emergency department with the following injuries: a fracture of the mandible with increasing obstruction of the airway, a sucking chest wound of the chest and an open fracture of the tibia with dry, crusted blood. After establishing an adequate airway, select the answer that has the treatments listed in correct priority sequence. 1. Close thoracic wound with a three-sided occlusive dressing. 2. Apply a sterile dressing to the fracture wound. 3. Assess LOC 1, 2, 3 1, 3, 2 3, 1, 2 3, 2, 1
1, 3, 2 You need to keep adequate breathing by intervening on the chest wound first (B). Next you need to assses for neuro deficits (D), so you would check GCS and pupils, finally you would apply a dressing to the wound (H). In some cases the wound would be a higher priority, but not in this situation. People rarely die of a fractured extremity, so remember the ABCD. They also direct your interventions. :-)
A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%
22.5% Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.
Which patient has the highest risk for deterioration and the nurse should see first? 29-year-old woman with a lacerated forehead, moderate bleeding and confusion. 41-year-old woman who fell and is unable to move her legs. 55-year-old man with a deep laceration to the left lower leg, bone protruding. 57-year-old man with burns to his face and covered with soot.
57-year-old man with burns to his face and covered with soot. Burns on the face indicate the potential for upper airway burns. Burns swell and airway can be cut off. Airway is a very high priority! :-)
Which of the following assessments reflects the appropriate order for an emergency assessment? Assessing airway, breathing and circulation should be performed after a thorough health history A quick head to toe assessment occurs initially, after a responsiveness check as part of the primary assessment. A brief neuro check, consisting of Level of consciousness and Glascow Coma Score is done as part of the primary assessment after the ABCs. Obtaining a full set of vital signs should occur immediately after determining responsiveness.
A brief neuro check, consisting of Level of consciousness and Glascow Coma Score is done as part of the primary assessment after the ABCs. The primary assessment is ABCDEFG. Airway, breathing, circulation, and then neuro. Full set of vitals is F and would come after ABCDE. A health history and head to toe is part of the secondary survey.
Which of the following should lead the RN to suspect that a client with a fracture of the right femur is developing a fat embolus? A. Acute respiratory distress syndrome B. Migraine-like headaches C. Numbness in the right leg D. Muscle spasms of the right thigh
A. Acute respiratory distress syndrome Where does the fat embolus usually go first? Lungs.
There has been a fire in the apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment. Select all that apply. A. An 8 y/o with 3rd degree burns over 10% of his body surface area (BSA) B. A 20 y/o who inhaled the smoke of the fire C. A 30 yo with 2nd degree burns on the back of his left leg D. A 40 y/o with 2nd degree burns on his right arm (about 10% of his BSA) E. A 50 yo with a hx of diabetes who sustained 1st and 2nd degree burns on his left forearm (about 5% BSA)
A. An 8 y/o with 3rd degree burns over 10% of his body surface area (BSA) B. A 20 y/o who inhaled the smoke of the fire E. A 50 yo with a hx of diabetes who sustained 1st and 2nd degree burns on his left forearm (about 5% BSA) B...you may want to watch and wait in reality, but on NCLEX → assume injury. Think about the Rule of 9's from ppt. Rationale from Quizlet: Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third- degree burns over 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.
12. The RN is caring for a client being treated for fat embolus after multiple fractures. Which data would the RN evaluate as the most favorable indication of resolution of the fat embolus? A. Clear mentation B. Minimal dyspnea C. Oxygen saturation of 85% D. Arterial oxygen level of 78mm Hg
A. Clear mentation
Eliciting a medical history is crucial during the initial assessment because A. Comorbidities and medications alter the physiologic response to trauma B. Obtaining an accurate history can assess the patient's orientation level C. A medical history helps to identify the cause of the trauma D. The patient may be comatose later
A. Comorbidities and medications alter the physiologic response to trauma D could be true too! Think about what is the main reason. A is a more complete and true answer
An RN is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. On the basis of this level, the RN would anticipate which of the following signs in the client? A. Flushing B. Dizziness C. Tachycardia D. Coma
A. Flushing Normal level of carbon monoxide in blood would be 0%. Usually in reality, they get "flu-like" symptoms first, dizziness, light-headedness, etc (cases that end up getting seen in the ED by us are usually not serious cases). When approaching these kinds of questions, think about the defining characteristic. Remember it's carbon MONOXIDE, not carbon DIOXIDE. 0 to 12% is also a big difference, so think severe. Use a non-rebreather to treat this patient. They can have regular SpO2 and be at 100%, but they're not getting enough oxygen.
A patient with SCI at C5 is being cared for in the ED while awaiting transport to a trauma center. Which of the following represents the highest priority for ongoing assessment? A. Monitor respiratory status B. Administer balanced resuscitation fluid C. Perform serial assessments of neurologic function D. Observe for signs of distributive shock
A. Monitor respiratory status
A client is admitted to the ED following a fall from home and the HCP prescribes insertion of a Foley catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The RN should take which action? A. Notify the HCP B. Use a small-sized catheter C. Administer pain medication before inserting the catheter D. Use extra povidone-iodine solution in cleaning the meatus
A. Notify the HCP Bleeding around the urinary meatus is not normal. Could be a kidney injury, torn ureter, etc. There is a trauma! You don't put a tube in for a trauma.
When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient (select all that apply.)? The exercises are the only way to prevent contractures. Active and passive ROM maintain function of body parts. ROM will show the patient that movement is still possible. Movement facilitates mobilization of leaked exudates back into the vascular bed. Active and passive ROM can only be done while the dressings are being changed.
Active and passive ROM maintain function of body parts. ROM will show the patient that movement is still possible. Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.
The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? Administer 100% humidified oxygen. Teach the patient deep breathing exercises. Encourage the patient to express his feelings. Assist the patient to a high Fowler's position.
Administer 100% humidified oxygen. Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.
The purpose of the secondary assessment is to A. Identify and intervene with life-threatening injuries B. Identify the existence of all injuries C. Facilitate treatment of airway and breathing D. Assess response of resuscitative interventions
Answer: B
A broken steering wheel should induce a high suspicion of injury to the: A. Head B. Neck C. Abdomen D. Long bones of the leg
Answer: C, abdomen. (and chest)
What 2 things can the "F" stand for in the secondary assessment?
Answer: Family presence and Full set of vitals
What is the most common organ injured in blunt trauma to the abdomen?
Answer: Spleen
You are drawing labs for your trauma patient when the monitor alarms for a BP of 70/40 (previous BP was 97/60). What will you assess next?
Answer: airway! Return to the primary survey when the patient becomes hemodynamically unstable during the secondary survey.
You are inspecting the posterior surface of a trauma patient when the cardiac monitor shows a change in rhythm. What will you assess next?
Answer: airway! Return to the primary survey when the patient becomes hemodynamically unstable during the secondary survey.
You are obtaining a history when your trauma patient loses consciousness. What will you assess next?
Answer: airway! Return to the primary survey when the patient becomes hemodynamically unstable during the secondary survey.
Blunt or penetrating trauma? Injuries less obvious and extent more difficult to diagnose, but potentially more life threatening.
Answer: blunt
Name a lab change that might indicate DIC?
Answer: decreased platelets, increased PT, PTT, d-dimer
When beginning the "E" component of the assessment, what do you need to take measure to prevent?
Answer: hypothermia
What do you need to know prior to turning a patient with a pelvic fracture?
Answer: if the fracture is stable or unstable.
Ecchymosis to the flank and periumbilical area indicates:
Answer: retroperitoneal bleeding
The client and his spouse were involved in a motorcycle accident in which the spouse was killed. The client, being treated for multiple rib fractures and a broken leg, asks the nurse which room his wife is in. Which response is appropriate? A. "Unfortunately your wife is not in the hospital at this time" B. "I'm sorry, but your wife did not survive that motor vehicle accident" C. "Let me get your family so that you can talk to them about your wife" D. "The doctor will be talking to you to let you know where she is located"
B. "I'm sorry, but your wife did not survive that motor vehicle accident" If time of death is already called/it's known the wife is in fact deceased, it's within your scope to tell the patient what happened. What's not in your scope if it's something that's not for sure (e.g. patient getting tested for leukemia. You have the test results back, and their husband starts asking what's wrong with their partner → the doctor has to talk about that with them). What about if someone asks if they're going to die? Their injuries are really bad and you know they might not make it? "Your injuries are very serious, but we're going to stay here with you. You won't be alone. We're doing everything we can to help you."
The RN is inserting an NG tube in a child admitted with head trauma. The RN should explain to the parents that the NG tube will be used for what purpose? A. Administer medications B. Decompress the stomach C. Obtain gastric specimens for analysis D. Provide adequate nutrition
B. Decompress the stomach With head traumas, they usually end up puking. There is risk for aspiration in this case. Emptying out their stomach so they won't puke is good. If NG tube is warranted for a head trauma, the situation for the child is probably severe enough. They don't do an NG tube for feeding purposes so soon after a head trauma case. In other cases though they do introduce nutrition ASAP.
An RN is working in the ED of a small local hospital when a client with multiple gunshot wounds arrives by ambulance. Which action by the RN is contraindicated in the handling of legal evidence? A. Initiate a chain of custody log B. Give clothing and wallet to the family C. Cut clothing along seams, avoiding bullet holes D. Place personal belongings in a labeled sealed paper bag
B. Give clothing and wallet to the family When there's a possible crime involved, you don't want to release anything that could be evidence.
Placement of an NG tube contraindicated during emergency care when the patient has a possible A. Inhalation injury B. Head or facial fracture C. Intra-abdominal bleed D. Cervical spine fracture
B. Head or facial fracture
A parent of a child with a moderate head injury asks the RN, "How will I know if my child is getting worse?" THe RN should tell the parent that the best indicator of the child's brain function is: A. The VS B. LOC C. Reaction of the pupils D. Motor strength
B. LOC With toddlers, think about observing them: change in LOC can be playing in a different way compared to their normal, not acting the way they usually are, etc.
A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation of the site was performed for 1 full hour. Upon the client's admission to the ED, the RN assesses the burn site and determines that the presence of which of the following is an indication that the chemical burn process is continuing? A. Eschar B. Liquefaction C. Cherry-red, firm tissue D. Intact blisters
B. Liquefaction Lye is a very basic (as in high pH) substance. Cherry-red is a classic sign of carbon monoxide poisoning.
An hour ago the HCP split the client's forearm cast due to severe arm pain, throbbing, and tingling. Which most important action should be taken by the nurse when the client's symptoms return? A. Administer an IV pain med B. Notify the health care provider immediately C. Cut the cast padding and spread the cast further D. Elevate the arm on pillows above heart level
B. Notify the health care provider immediately What's causing compartment syndrome? Continuing bleeding and giant hematoma inside probably.
A pt is admitted with an open fracture of the tibia after a bicycle accident. During assessment of the patient, the nurse questions the patient specifically about: A. Any previous injuries to the leg B. The status of tetanus immunization C. The use of antibiotics in the last month D. Whether the injury was exposed to dirt or gravel
B. The status of tetanus immunization
Endotracheal or tracheostomy tubes are placed in clients who have experienced: A. Electrical burns of the hands and arms causing arrhythmias B. Thermal burns to the head, face, and airway resulting in hypoxia C. Chemical burns on the chest and abdomen D. Second hand smoke inhalation
B. Thermal burns to the head, face, and airway resulting in hypoxia Airway resulting in hypoxia!
The burned client needs fluid replacement because massive amounts of fluid are lost. The rate at which IV fluids are infused is based on the burn client's: A. Lean muscle mass and body surface area (BSA) burned B. Total body weight and BSA burned C. Total BSA and BSA burned D. Height and weight and BSA burned
B. Total body weight and BSA burned
An RN is administering IV fluids as prescribed to a client who sustained second- and third-degree burns of the back and legs. In evaluating the adequacy of fluid resuscitation, the RN understands that which of the following would provide the most reliable indicator for determining the adequacy? A. VS B. Urine output C. Peripheral pulses D. Mental status
B. Urine output What does your kidneys need to make urine output? Water! If they're hydrated, they're going to make urine. Pulses are not as specific too.
A client arrives at the ED after a burn injury that occurred in the basement of the client's home. An inhalation injury is suspected. Which of the following treatments would the RN anticipate to provide to the client? A. 100% oxygen via a tight-fitting rebreather face mask B. Oxygen via NC at 5L C. 100% oxygen via a tight-fitting non-rebreather face mask D. Oxygen via NC at 10L
C. 100% oxygen via a tight-fitting non-rebreather face mask There's carbon monoxide in smoke. You want to do non-rebreather to get all the toxins out. What's likely to be an intervention for this patient? Intubation! And you want to hyperoxygenate them before that.
The RN assesses that the client has some finger swelling of a newly casted right arm fracture with no other abnormal findings. Which is the nurse's priority action? A. Notify the HCP immediately B. Split the cast to prevent constriction C. Elevate the casted arm on pillows D. Document the degree of finger swelling
C. Elevate the casted arm on pillows
An RN is caring for a client who sustained second- and third-degree burns on the anterior lower legs and anterior thorax. Which of the following does the RN expect to note during the emergent phase of the burn injury? A. Decreased HR B. Increased BP C. Elevated Hct levels D. Increased urinary output
C. Elevated Hct levels This is a pretty decent burn, so it went through a lot of layers of the skin. Losing fluids...so you would be dehydrated and then that would lead to falsely elevated Hct. Remember this is an early burn phase. Once you realize this is a dehydration question, it's pretty straight forward.
Which of the following are important interventions for the patient with multiple rib fractures? A. Chest tube placement B. Needle aspiration C. Pain management and pulmonary hygiene Placing a gauze dressing over the wound
C. Pain management and pulmonary hygiene Answer: C - they are at high risk for atelectasis and pneumonia
A client's chest tube is connected to a drainage system with a water seal. The RN notes that the fluid in the water-seal chamber is fluctuating with each breath the client takes. The fluctuation means that: A. There's an obstruction in the chest tube B. The client is developing subcutaneous emphysema C. The chest tube system is functioning properly D. There is a leak in the chest tube system
C. The chest tube system is functioning properly
The client is admitted to the ED after a sports injury. The client verbalizes extreme shoulder pain, and the nurse sees that the client's right arm is shorter than the left. What should the nurse do initially? Select all that apply. A. Lift the right arm to support it with a pillow B. Apply a covered ice pack to the left shoulder C. Prepare the client for immediate surgical repair D. Check the pulses and sensation of the right arm E. Prepare to administer an analgesic as prescribed F. Inspect the left shoulder for swelling and bruising
D. Check the pulses and sensation of the right arm E. Prepare to administer an analgesic as prescribed They should tell you which shoulder is painful...this is kind of a bad question. Arm can be shorter because muscle tries to pull it up and length of one arm can be shorter than the other in result.
A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure? A. Crackles B. Jaundice C. Generalized edema D. Dark, scanty urine
D. Dark, scanty urine If you have compartment syndrome you'll be thinking muscle damage. Could be rhabdo → dark urine. Urine output is also a good indicator that something is wrong. Unless it's HF then you use the weight. You would give them a ton of fluids to treat this patient.
The nurse is caring for a client involved with an MVA who sustained an unstable pelvic fracture. Which HCP order should be the nurse's priority? A. Urinalysis and culture and sensitivity B. Blood alcohol level and toxicology screen C. Computed tomography (CT) scan of the pelvis D. Give 2 units of cross-matched whole blood
D. Give 2 units of cross-matched whole blood In reality you could be doing more than one thing at once, but in terms of answering questions on the NCLEX, ID the priority thing you have to do when answering questions. Cross-matching usually takes a while so you want to get that started. In really emergent cases though they may just give them O-negative if pressed on time.
The nurse suspects a fat embolism rather than a pulmonary embolism from a venous thrombosis in the patient with a fracture who develops A. Tachycardia and dyspnea B. A sudden onset of chest pain C. ECG changes and decreased PaO2 D. Petechiae around the neck and upper chest
D. Petechiae around the neck and upper chest The other answers are PE symptoms, and D is the only different answer. 50-60% of cases have D as a symptom.
An RN is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The RN understands that the anticipated therapeutic outcome of the escharotomy is A. Brisk bleeding from the site B. Formation of granulation tissue C. Decreasing edema formation D. Return of distal pulses
D. Return of distal pulses What is eschar? Thick, leathery tissue that won't stretch. Circumferential → all the way around, so it's being compressed. Purpose of the escharotomy is to return circulation then.
The RN is one of several people who witnessed a vehicle hit a pedestrian at fairly low speed on a small street. The victim is dazed and tries to get up. The leg appears fractured. Which intervention should the nurse take? A. Try to reduce the fracture manually B. Assist the victim to get up and walk to the sidewalk C. Leave the victim for a few moments to call for an ambulance D. Stay with the victim and encourage the person to remain still
D. Stay with the victim and encourage the person to remain still You could assist with a reduction, but you won't be doing a manual reduction on a fracture. Whenever Jason sees a trauma case, he always thinks "distract and treat"!
A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment? A. Inability to move toes B. Cyanosis of toes C. Complaints of cast tightness D. Tingling in toes
D. Tingling in toes
The major preventable cause of death in the trauma patient is: A. Airway compromise B. Ineffective ventilation C. Secondary head injury D. Uncontrolled hemorrhage
D. Uncontrolled hemorrhage
In the primary assessment the D stands for:
Disability (and sometimes deformities)
In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? Serum sodium and potassium increase. Serum sodium and potassium decrease. Edema and arterial blood gases improve. Diuresis occurs and hematocrit decreases.
Diuresis occurs and hematocrit decreases. In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs so potassium levels decrease at the end of the emergent phase when fluid levels normalize.
Which of the following is an example of a traumatic emergency? Aspirin overdose Status asthmaticus Myocardial Infarction Electrical shock
Electrical shock Aspirin overdose, Status asthmaticus, and myocardial infarction are medical emergencies. You are right!!! This is an example of a traumatic emergency while the other 3 answers are examples of medical emergencies.
Once a patient has been diagnosed with flail chest by x-ray, additional imaging is not necessary when new or increased pain is later reported by the patient. True or False? True False
False New pain reported after any chest or abdominal injury should be further investigated with imaging because internal damage could progress or occur secondary to the trauma, such as internal bleeding or organ damage.
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods
High-calorie and high-protein foods A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.
A nurse is attempting to provide breaths to a patient using a bag-valve-mask during a code. It feels hard to bag and the nurse doesn't see chest rise. What should the nurse do next? Turn up the oxygen Ask someone to get them a new bag Insert an oropharyngeal airway Ask for help squeezing the bag harder
Insert an oropharyngeal airway The first intervention is to attempt to open up the airway to allow ventilation. An oropharyngeal is a quick way to do this and should be attempted first. You would most likely perform a jaw-thrust first as well. Getting a new bag may be warranted if no other option works. Squeezing the bag tighter is not an option as it could create dangerous pressures in the lungs. The oxygen should already be turned up, and that wouldn't fix this problem.
An older adult patient is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home? Cook for her. Stop her from smoking. Install tap water anti-scald devices. Be sure she uses an open space heater.
Install tap water anti-scald devices. Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.
The best method to use for opening an airway in a client who is unconscious after being hit by a car is: Head tilt, Jaw lift Cricoidthyrotomy Jaw thrust maneuver Blind nasal intubation
Jaw thrust maneuver We start from least invasive and quick first. We wouldn't want to tilt their head since they could have a spinal cord injury. A jaw thrust allows us to maintain c-spine precautions and open their airway.
When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? Mannitol 75 g IV Urine for myoglobulin Lactated Ringer's solution at 25 mL/hr Sodium bicarbonate 24 mEq every 4 hours
Lactated Ringer's solution at 25 mL/hr Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's solution at 2 to 4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.
The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? Begin IV fluid replacement. Monitor for signs of complications. Assess and manage pain and anxiety. Discuss possible reconstructive surgery.
Monitor for signs of complications.
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.
A chest trauma client is experiencing acute respiratory distress and chest pain. The nurse, when performing an assessment, notes absent breath sounds in the right upper chest, an increased heart rate, and tachypnea. These findings are most consistent with: Hemothorax Pneumothorax Congestive Heart Failure Pulmonary embolism
Pneumothorax Pneumothoraces classically present with symptoms of chest discomfort, tachycardia, tachypnea due to respiratory distress, and dim to absent upper lung sounds on affected side. Although the manifestations of a hemothorax are the same as pneumothorax, the nurse would expect the absent breath sounds to be in the lower parts of the lung field(s) as blood or fluid settles due to gravity. Although you may see respiratory distress, cyanosis and changes in heart rate with CHF, absent breath sounds are not attributable to this condition. While a pulmonary embolism would cause acute respiratory distress and chest pain, absent breath sounds are not usually a finding.
A 5 year-old child fell into a backyard pool and was found 3 minutes later floating face down. What is the cause of the greatest risk for death for this patient? Pulmonary edema. C-spine injury. side effects from Mannitol and Lasix. hypothermia.
Pulmonary edema. The child would have fresh (but chemically treated) water in the lungs which would destroy the surfactant and alveoli. Treatment would focus on correcting the pulmary failure from such edema. The child would be in c-spine precautions and need his neck cleared at some point, the biggest consequence of drowning is pulmonary edema. This child was in the water for only 3 minutes and that is not enough time to drop his core temperature. Though hypothermia can be a significant problem in drownings, it is not the greatest consequence in this particular case.
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands
Reddening of the skin The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury (select all that apply.)? Singed nasal hair Generalized pallor Painful swallowing Burns on the upper extremities History of being involved in a large fire
Singed nasal hair Generalized pallor Painful swallowing History of being involved in a large fire Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.
The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? Skin is hard with a dry, waxy white appearance. Skin is shiny and red with clear, fluid-filled blisters. Skin is red and blanches when slight pressure is applied. Skin is leathery with visible muscles, tendons, and bones.
Skin is shiny and red with clear, fluid-filled blisters. Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.
The nurse is triaging a patient who was in a motor vehicle accident. Which response by the patient would reveal the most severe mechanism of injury? My neck is really sore. I was driving about 25 mph. The fender is smashed in. The car was totaled.
The car was totaled. A totaled car would indicate a large amount of impact and force where exerted. A sore neck would be expected even in a minor collision. Driving 25 mph is significant but not the most severe. A damaged part of the care is also indicative of a major impact, but not the most severe.
The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation (select all that apply.)? Urine output is 46 mL/hr. Heart rate is 94 beats/min. Urine specific gravity is 1.040. Mean arterial pressure is 54 mm Hg. Systolic blood pressure is 88 mm Hg.
Urine output is 46 mL/hr. Heart rate is 94 beats/min. Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030.
Which of the following statements best describes the relationship between ARDS and MODS? a. Decreased ventilation leads to decreased tissue oxygenating and cellular death b. Pulmonary edema produces a fluid volume deficit and hypoperfusion of tissues c. Organ death releases endotoxins that kill pulmonary epithelial cells. d. Increased carbon dioxide retention stimulates peripheral vasodilation and hypoperfusion of tissues.
a. Decreased ventilation leads to decreased tissue oxygenating and cellular death
The optimal placement for a chest drain valve (Heimlich) used to treat small a pneumothorax is: anteriorly at the second intercostal space, mid-clavicular. posteriorly through the eighth intercostal space. midanterior chest through the mediastinal incision. through the space above the clavicle into the apex of the lung.
anteriorly at the second intercostal space, mid-clavicular. Second intercostal space mid clavicular is the usual placement for a pneumothorax. The "universal placement" for a chest tube is in the 4th intercostal space, mid-axillary to allow drainage of both pneumo- and hemothoraces. You are correct! This is the usual placement for a pneumothorax. The "universal placement" for a chest tube is in the 4th intercostal space, mid-axillary to allow drainage of both pneumo- and hemothoraces.
A patient has an impaled knife in the upper abdomen. You should immediately: a. Remove the knife and apply pressure. b. Manipulate the knife to facilitate assessment of injured organs c. Stabilize the knife without removal and minimal manipulation d. Leave the knife alone
c. Stabilize the knife without removal and minimal manipulation Answer: C! Do not remove an impaled object until you are in a controlled environment like the OR - the object may be preventing hemorrhage. You should stabilize to prevent further damage.