Critical care master final sett

28. A male patient, 16 years old, comes to the emergency department (ED) after burning his right hand and arm while working on a friend's car. The injury is determined to be a superficial burn and it is treated. What would the nurse teach the patient before discharging him home to return on a daily basis for dressing changes? A) "As your arm swells, push on your fingernails. If it takes longer than 5 seconds for them to get pink come back to the ED." B) "You should be fine until you come back tomorrow for your dressing change." C) "Drink lots of fluids and elevate the arm." D) "The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED."

"The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED." **In a superficial burn there is loss of capillary integrity and fluid is localized to the burn itself, resulting in blister formation and edema only in the area of injury. Capillary refill should be 3 seconds or less. Options B and C are distracters for this question.

17. A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What percentage of burn does the patient have? A) 10% B) 25% C) 9% D) 18%

18% **When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.

18. The most common cause of secondary immunodeficiency disorders is:

18. drug induced immunosuppression with antineoplastic agents and corticosteroids.

7. The nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) A week

2 DAYS **Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

20. A transplant rejection which most commonly occurs with kidney transplant.

20. Hyperacute

21.Organ must be removed when "this" transplant rejection occurs.

21. Hyperacute

22. A transplant rejection which Infiltration of the organ with B and T lymphocytes occur.

22. Chronic

23. Treatment is supportive with this transplant rejection.

23. Chronic

24. In this type of transplant rejection the recipient's T-cytotoxic lymphocytes attack the foreign organ.

24. Acute

6. The emergency department nurse has just admitted a patient with a burn. The nurse recognizes that the patient is likely to experience a local and systemic response to the burn when the burn exceeds a total body surface area (TBSA) of what? A) 10% B) 15% C) 20% D) 25%

25% **If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction. Often, patients with large burns become nauseated as a result of the gastrointestinal effects of the burn injury, such as paralytic ileus, and the effects of medication such as opioids. All patients who are intubated should have a nasogastric tube inserted to decompress the stomach and prevent vomiting.

25. A transplant rejection which usually reversible with additional or increased immunosuppressant therapy.

25. Acute

26. A transplant rejection which occurs when recipient has antibodies against donor's histocompatibility Leukocyte antigens (HLA's)

26. Hyperacute

27. Transplant rejection which requires long-term use of immunosuppressant necessary to combat the rejection

27. Acute

28. Irreversible, transplant rejection, immune-mediated injury to transplanted organ

28. Chronic

29. Hyperacute transplant rejection

29. *Humoral immunity* /*antibody-mediated immune system* 1. a rejection that usually develops immediately after the implantation of a vascular graft; may be caused by preformed, cytotoxic antibodies to the graft; 2. a form of antibody-mediated, usually irreversible damage to a transplanted organ, particularly the kidney, manifested predominantly by diffuse thrombotic lesions, usually confined to the organ itself and only rarely disseminated

30. Acute transplant rejection

30. Developing with formation of *cellular immunity*, acute rejection occurs to some degree in all transplants, except between identical twins, unless immunosuppression is achieved (usually through drugs). Acute rejection begins as early as one week after transplant, the risk being highest in the first three months, though it can occur months to years later. Highly vascular tissues such as kidney or liver often host the earliest signs—particularly at endothelial cells lining blood vessels—though it eventually occurs in roughly 10 to 30% of liver transplants, and 50 to 60% of kidney transplants. A single episode of acute rejection can be recognized and promptly treated, usually preventing organ failure, but recurrent episodes lead to chronic rejection. It is believed that the process of acute rejection is mediated by the cell mediated pathway, specifically by mononuclear macrophages and T-lymphocytes.

31. Chronic transplant rejection

31. Chronic rejection explains *long-term morbidity* in most lung-transplant recipients, the median survival roughly 4.7 years, about half the span versus other major organ transplants. In histopathology the condition is bronchiolitis obliterans, which clinically presents as progressive airflow obstruction, often involving dyspnea and coughing, and the patient eventually succumbs to pulmonary insufficiency or secondary acute infection.

24. You have just reported to the burn unit to start your shift. Four new patients have been admitted in the past 12 hours. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old healthy male burned over 36% of his body in a car accident C) A 39-year-old female with myasthenia gravis burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

A 4 YEAR OLD SCALD VICTIM BURNED OVER 24% FO THE BODY **Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.

23. A 45-year-old man is brought in by Life-Flight after a motor vehicle accident is which he was trapped in a burning vehicle. The burn team is estimating the patient's likelihood of survival based on the severity of the burn injury. The emergency department nurse knows that the severity of the injury is based on what factors? (Mark all that apply.) A) Age B) Depth of the burn C) Presence of inhalation injury D) Family support E) Psychological state of the patient

A, B, C AGE, DEPTH OF THE BURN, PRESENCE OF INHALATION INJURY **The severity of each burn injury is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan the care for each patient. These factors include age of the patient; depth of the burn; amount of surface area of the body that is burned; presence of inhalation injury; presence of other injuries; location of the injury in special care areas such as the face, perineum, hands, and feet; and presence of a past medical history. Options D and E are not factors that bear on the severity of the injury.

40. A patient in the rehabilitation phase of the burn injury is setting goals with the nurse. What goals would be appropriate at this time? (Mark all that apply.) A) Increased participation in activities of daily living B) Increased understanding of the planned follow-up care C) Increased control of treatment D) Adjustment to alterations in lifestyle E) Recognition of complications

A, B, D INCREASED PARTICIPATION IN ADLs, INCREASED UNDERSTANDING OF THE PLANNED FOLLOW-UP CARE, ADJUSTMENT TO ALTERATIONS IN LIFESTYLE **The major goals for the patient include increased participation in activities of daily living; increased understanding of the injury, treatment, and planned follow-up care; adaptation and adjustment to alterations in body image, self-concept, and lifestyle; and absence of complications.

37. Your patient is in the acute phase of a burn injury. One of the nursing diagnoses on the plan of care is ineffective coping due to burn injury and altered body image. What interventions can you institute to help this patient cope more effectively? (Mark all that apply.) A) Promote truthful communication B) Allowing the patient to set specific expectations C) Assist the patient in practicing appropriate strategies D) Stop the patient's manipulation of staff E) Give positive reinforcement when appropriate

A,C,E PROMOTE TRUTHFUL COMUNICATION, ASSIST THE PATIENT IN PRACTICING APPROPRIATE STRATEGIES, GIVE POSITIVE REINFORCEMENT WHEN APPROPRIATE **The nurse can assist the patient to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the patient practice appropriate strategies, and giving positive reinforcement when appropriate. The nurse should set specific expectations, not the patient. Each staff member needs to stop the manipulation of the patient with the involved staff member.

Urinary function during the acute phase of spinal cord injury is maintained with a. an indwelling catheter b. intermittent catheterization c. insertion of a suprapubic catheter d. use of incontinent pads to protect the skin

A. an indwelling catheterization

2. The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

ACUTE **The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (ie, wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

13. The nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity intolerance B) Anxiety C) Impaired nutrition: less than body requirements D) Acute pain

ACUTE PAIN **Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid diagnoses, the presence of pain may contribute to these diagnoses and management of the patient's pain is priority as it may have a direct correlation to these nursing diagnoses.

16. A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

AIRWAY MANAGEMENT **Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

22. Where do most burn injuries occur? A) On the road B) At home C) At work D) Recreational accidents

AT HOME ** Of those people admitted to burn centers, 47% are injured at home, 27% on the road, 8% are occupational, 5% are recreational, and the remaining 13% are from other sources.

A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min. Which of the following acctions should the nurse take first? a. notify the provider b. sit the client upright in bed c. check the client's urinary catheter for blockage d. administer antihypertensive medication

B. sit the client upright in bed Rationale: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated BP. The first action by the nurse is elevate the head of the bed until the client is in an upright position. this will lower the BP secondary to postural hypotension.

A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse he is recovering some function. The nurses' best response to the patient is, a. it is really still too soon to know if you will have a return of function b. the could be a really positive finding. can you show me the movement c. that's wonderful. we will start exercising your legs more frequently now d. im sorry, but the movement is only a reflex and does not indicate normal function

B. the could be a really positive finding. can you show me the movement Rationale: in 1 week following a spinal cord injury, there may be a resolution of the edema of the injury and an end to spinal shock. When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function, but with the resolution of edema, some normal function may also occur. it is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled, which would indicate some return of function.

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is, a. you will have more normal function when spinal shock resolves and the reflex arc returns b. the extent of your injury cannot be determined until the secondary injury to the cord is resolved c. when your condition is more stable, an MRI will be done that can reveal the extent of the cord damage d. because long-term rehabilitation can affect the return of tunction, it will be years before we can tell when the complete effect will be

B. the extent of your injury cannot be determined until the secondary injury to the cord is resolved Rationale: Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock, and the reflexes may be inappropriate and excessive, causing spasms that complicate rehab.

32. As the patient begins the acute phase of a burn, cautious administration of fluids and electrolytes continues. The nurse knows that this caution is because of what? (Mark all that apply.) A) Patient is considered in critical condition B) Cardiac function is decreased C) Patient's physiologic responses to the burn injury D) Losses of fluid from large burn wounds E) Shifts in fluid from the interstitial to the intravascular compartment

C) Patient's physiologic responses to the burn injury D) Losses of fluid from large burn wounds E) Shifts in fluid from the interstitial to the intravascular compartment **Cautious administration of fluids and electrolytes continues during this phase of burn care because of the shifts in fluid from the interstitial to the intravascular compartment, losses of fluid from large burn wounds, and the patient's physiologic responses to the burn injury.

An initial incomplete spinal cord injury often results in complete cord damage because of a. edematous compression of the cord above the level of the injury b. continued trauma to the cord resulting from damage to stabilizing ligaments c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. mecheanical transection of the cord by sharp vertebral bone fragments after the initial injury

C. c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the patho of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine. resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may increase the damage as it extends above and below the injury site.

12. An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What factors does the nurse know are considered when determining the depth of burn? A) Causative agent B) Visual observation of burned area C) Area of body burned D) Circumstances of the accident

CAUSATIVE AGENT **The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. To determine the depth of the burn you do not take into consideration you visual observation of the burned area, how much of the body is burned, or the circumstances of the accident.

34. A nurse is caring for a patient during the acute phase of the burn. The nurse knows he is responsible for what? A) Restricting visitors to prevent infection B) Closely scrutinizing the burn wound to detect early signs of infection C) Cleaning the patient's room D) Maintaining the patient in a sterile environment

CLOSELY SCRUTINIZING THE BURN WOUND TO DETECT EARLY SIGNS OF INFECTION **The nurse is responsible for providing a clean and safe environment and for closely scrutinizing the burn wound to detect early signs of infection. Visitors are not restricted to a burn patient. The nurse does not clean the patient's room. The patient is maintained in a clean environment, not a sterile environment.

15. The nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) Daily for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury

CONTINUOUSLY Garments are worn continuously (ie, 23 hours a day).

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure

Correct Answer: 1 Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.

Which patient is at highest risk for a spinal cord injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team

Correct Answer: 1 Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.

An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed? Select all that apply. 1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 3. The patient will be placed on a ventilator. 4. The head of the bed will be elevated. 5. The patient's head will be secured with a belt or tape secured to the stretcher.

Correct Answer: 1,2,5 Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.

Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

Correct Answer: 2 Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.

The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? 1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury for two cord segments above and below the affected level." 3. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury."

Correct Answer: 2 Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury.

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion

Correct Answer: 2,4,5 Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.

A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction

Correct Answer: 2,5 Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction. The other answers will not cause autonomic dysreflexia.

While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia

Correct Answer: 3 Rationale: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.

The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.

Correct Answer: 3 Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.

Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy? 1. Provide the patient with an air mattress. 2. Place pillows under patient to help patient turn. 3. Teach the patient to grasp the side rail to turn. 4. Use the log roll to turn the patient to the side.

Correct Answer: 4 Rationale: A patient who has undergone a laminectomy needs to be turned by log rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but the patient still needs to be turned frequently. Placing pillows under the patient can help take pressure off of one side but the patient still needs to change positions often. Teaching the patient to grasp the side rail will cause the spine to twist, which needs to be avoided.

A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation? 1. hemiplegia 2. paresthesia 3. paraplegia 4. quadriplegia

Correct Answer: 4 Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.

Correct Answer: 4 Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.

13. Patients with a heart transplantation are at rick for which of the following complication in the first year after transplantation? (select all that apply) a. Cancer b. Infection c. Rejection d. Vasculopathy e. Sudden Cardiac Death

Correct answers: b, c, e b. Infection c. Rejection e. Sudden Cardiac Death Rationale: A variety of complications can occur after heart transplantation. In the first year after transplantation, the major causes of death are acute rejection and infection. Heart transplant recipients also are at risk for sudden cardiac death. Later, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease) are major causes of death.

Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, the nurse anticipates that the patient will need a. IV fluids b. tube feedings c. parenteral nutrition d. nasogastric suctioning

D. nasogastric suctioning Rationale: During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur, and NG suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileus. Tube feedings would be used only for patients who had difficulty swallowing and not until peristalsis is returned; PN would be used only if the paralytic ileus was unusally prolonged.

A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintainance of an airway and provision of ventilator support as needed is the priority intervention.

27. An emergency department nurse has just received a burn victim brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. The nurse knows that pathophysiologic changes resulting from major burns during the initial burn-shock period include what? A) Hyper-dynamic anabolism B) Hyper-metabolic catabolism C) Decreased cardiac output D) Organ hyper-function

DECREASED CARDIAC OUTPUT **Pathophysiologic changes resulting from major burns during the initial burn-shock period include tissue hypo-perfusion and organ hypo-function secondary to decreased cardiac output, followed by a hyper-dynamic and hyper-metabolic phase. Options A and B are distracters for this question.

26. A burn victim is admitted to the Intensive Care Unit to stabilize and begin fluid resuscitation before transport to the burn center. If inadequate fluid resuscitation occurs what happens to the patient? A) Becomes unresponsive B) Distributive shock C) Death D) Hypovolemic shock

DISTRIBUTIVE SHOCK Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output. Despite adequate fluid resuscitation, cardiac filling pressures (central venous pressure, pulmonary artery pressure, and pulmonary artery wedge pressure) remain low during the burn-shock period. If inadequate fluid resuscitation occurs, distributive shock occurs

31. The acute phase of the burn begins 48 to 72 hours after the burn. What begins at this time? A) Cardiac output decreases B) Renal failure begins C) Diuresis D) Fluid moves from intravascular compartment to interstitial spaces

DIURESIS **As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. Cardiac output should increase and renal output should increase.

8. A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners

EARLY AND ENTERAL FEEDING **If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.

9. A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient? A) Fluid status B) Risk of infection C) Body image D) Level of pain

FLUID STATUS **During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection, body image, and pain are significant areas of concern, but are less urgent than fluid status.

1. A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

FULL THICKNESS **A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Full partial thickness is not a depth of burn. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis and the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis and the patient will complain of pain and sensitivity to cold air.

25. A burn patient is brought to the emergency department. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Metabolic acidosis C) Hypovolemia D) Hyperkalcemia

HEMODYNAMIC INSTABILITY **The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. Options B, C, and D occur, they are just not the first event to happen.

20. Grafts taken from one body and grafted onto another body are called what? A) Allograft B) Homograft C) Heterograft D) Autograft

HOMOGRAFT **Homografts are grafts derived from one person's body and used on another part of a different person's body.

3. A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis

HYPERKALEMIA, HYPONATREMIA, ELEVATED HEMATOCRIT AND METABOLIC ACIDOSIS **Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amount of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

30. A nurse on the burn unit is caring for a patient who has gone into the acute phase of her burn. What would be important for the nurse to monitor the patient for? A) Hypometabolism B) Hyponatremia C) Hyperkalemia D) Hypoglycemia

HYPONATREMIA **Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space. Hypermetabolism can occur up to 1 year after the burn. Hyperkalemia occurs in the emergent phase of the burn. In a burn patient there is a hyperglycemic response, not a hypoglycemic response.

14. The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area and seek medical attention.

IMMERSE THE CHILD IN A COOL BATH **After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. You do not put ice on the burn, nor do you put butter on the burn. You do not need to avoid touching the burn.

29. A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and both legs. The burns to the lower legs are circumferential. The nurse knows to monitor closely for what as the edema in this patient increases? A) Ischemia B) Eschar C) Hyper-profusion to the burned area D) Increased fluid loss through the burned area

ISCHEMIA **As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. The physician may need to perform an escharotomy, a surgical incision into the eschar (devitalized tissue resulting from a burn), to relieve the constricting effect of the burned tissue.

4. The patient you are caring for has an electrical burn and has developed thick eschar over the burn wound. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat

MAFENIDE ACETATE 10% (SULFAMYLON) HYDROPHILIC-BASED CREAM **Mafenide acetate 10% hydrophilic-based cream is the agent of choice for electrical burns because of its ability to penetrate thick eschar.

38. What is a priority in the rehabilitation phase of the burn injury? A) Monitoring fluid and electrolyte imbalances B) Patient and family education C) Assessing wound healing D) Documenting family support

PATIENT AND FAMILY EDUCATION **Patient and family education is a priority in the acute and rehabilitation phases. There should be no fluid and electrolyte imbalances in the rehabilitation phase. Assessing wound healing is an ongoing function but it is not a priority in the rehabilitation phase. Documenting family support is not a priority in the rehabilitation phase.

19. The nursing students are doing clinical hours on the burn unit. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

PREVENT CONTRACTURES **To prevent the complication of contractures the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures.

36. You are caring for a burn patient who is in the later stages of the acute phase of the burn injury. What is an important factor in your care of the patient? A) Immobilizing the patient B) Maintaining splints and functional devices C) Maintaining ongoing discussion about the patient with a psychologist D) Prevention of DVT

PREVENTION OF DVT **Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices, but does not maintain them. The nurse does not maintain discussion with a psychologist about the patient.

18. The nursing instructor is teaching about the emergent/resuscitative phase of burn injury. During this phase, what would the nursing instructor tell the students they should closely monitor in the laboratory values? A) Sodium deficit B) Bleeding time C) Potassium deficit D) Decreased hematocrit

SODIUM DEFICIT **Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include potassium excess, sodium deficit, base-bicarbonate deficit, and elevated hematocrit.

35. It is time to change the dressings on a burn patient. What does the nurse do to reduce pain and discomfort at this time? A) The nurse lets the patient decide on when to change the dressing. B) The nurse skip's the dressing change if the patient is really uncomfortable. C) The nurse changes dressings as quickly as possible. D) The nurse lets the aide do the painful part of the dressing change.

THE NURSE CHANGES DRESSINGS AS QUICKLY AS POSSIBLE **The nurse works quickly to complete treatments and dressing changes to reduce pain and discomfort. Letting the patient decide the time of the dressing change lets the patient feel more in control. It doesn't reduce pain and discomfort. The nurse should never skip an ordered dressing change. You never delegate a dressing change on a burn patient.

33. What is the nursing goal during the acute phase of a burn? A) To ultimately prevent or control infection in the burn population B) To prevent hypervolemia in the burn population C) To manage pain in a proactive way for the patient's comfort D) To provide emotional support as the changes in body image become internalized in the patient

TO ULTIMATELY PREVENT OR CONTROL INFECTION IN THE BURN POPULAITON **The nursing goal is to provide protection and safety in the patients' environment to ultimately prevent or control infection in the burn population. This makes options B, C, and D incorrect.

11. A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the appropriate nursing intervention when this separation occurs? A) Reinforce the Biobrane dressing with another piece of Biobrane. B) Remove the Biobrane dressing and apply a new dressing. C) Trim away the separated Biobrane. D) Notify the physician for further emergency related orders.

TRIM AWAY THE SEPARATED BIOBRANE **As the Biobrane gradually separates, it is trimmed, leaving a healed wound. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. You would not reinforce the Biobrane, or remove it and apply a new dressing. Nor would you notify the physician for further orders.

10. The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve: A) A spontaneous separation of dead tissue from the viable tissue B) Use of surgical scissors, scalpels or forceps to remove the eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound

USE OF SURGICAL SCISSORS, SCALPELS OR FORCEPS TO REMOVE THE ESCHAR UNTIL THE POINT OF PAIN AND BLEEDING OCCURS **Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accomplished through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Early wound closure and shaving the burned skin layers are examples of surgical debridement.

5. The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How will the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.

WRAP COOL TOWELS AROUND AFFECTED EXTREMITY INTERMITTANTLY **Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. However, 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.

39. A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse "I can't wait to have surgery to reconstruct my face so I look normal again." What would be the nurse's best response? A) "You know, nothing can be done until your scars mature. It is something the doctor will talk to you about in the first few years after discharge." B) "That is something for you to talk to your doctor about." C) "I know this is really important to you, but you have to realize that no one can make you look like you used to." D) "You will have most of these scars for the rest of your life."

YOU KNOW, NOTHING CAN BE DONE UNTIL YOUR SCARS MATURE. IT IS SOMETHING THE DOCTOR WILL TALK TO YOU ABOUT IN THE FIRST FEW YEARS AFTER DISCHARGE **Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Options B and C are true statements but not the best statements. The nurse does not know for sure how much reconstruction can be done.

21. A nurse taking care of a burn patient is asked why the patient is losing so much weight. What would be the nurse's most appropriate answer? A) "Your body has built up extra fat deposits even though you haven't been eating very much." B) "Your body has used your fat deposits for fuel because you haven't been eating very much." C) Your reserve fat deposits have been catabolized because you have been eating so much." D) You have lost fluids and you haven't eaten very much."

YOUR BODY HAS USED YOUR FAT DEPOSITS FOR FUEL BECAUSE YOU HAVEN'T BEEN EATING VERY MUCH **Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized, fluids are lost, and caloric intake may be limited.

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinski's reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities

a

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage? A) Hyperthermia B) Tachycardia C) Hypertension D) Bradypnea

a

6. A patient is admitted to the hospital with acute rejection of a kidney transplant. The nurse will anticipate a. administration of immunosuppressant medications. b. insertion of an arteriovenous graft for hemodialysis. c. placement of the patient on the transplant waiting list. d. drawing blood for human leukocyte antigen (HLA) and ABO compatibility matching.

a. administration of immunosuppressant medications ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is reversible, there is no indication that the patient will require another transplant, hemodialysis, or HLA/ABO testing. DIF: Cognitive Level: Application REF: 229-230

4. A patient who received a bone marrow transplant for treatment of leukemia develops a skin rash 10 days after the transplant. The nurse recognizes this reaction as an indication that the: a.donor T cells are attacking the patient's skin cells. b. patient's antibodies are rejecting the donor bone marrow. c. patient is experiencing a delayed hypersensitivity reaction. d. patient will need treatment to prevent hyperacute rejection.

a. donor T cells are attacking the patient's skin cells. The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity. DIF: Cognitive Level: Comprehension REF: 232

16. The nurse plans long-term goals for the patient who has had a heart transplant with the knowledge that a common cause of death in heart transplant patients during the first year is: a. infection b. heart failure. c. embolization d. malignant conditions

a. infection Because of the need for long-term immunosuppressant therapy to prevent rejection, the patient with a transplant is at high risk for infection, a leading cause of death in transplant patients. Acute rejection episodes may also cause death in patients with transplants, but can be successfully treated with augmented immunosuppressive therapy. Malignancies occur in patients with organ transplants after taking immunosuppressants for a number of years.

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia

b

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? A) Prepare to transfuse packed red blood cells. B) Prepare for interventions to increase the patient's BP. C) Place the patient in the Trendelenberg position. D) Prepare an ice bath to lower core body temperature.

b

19. A common combination of immunosuppressive agents used to prevent rejection of transplanted organs is: a. cyclosporine, sirolimus, and muromonab-CD3 b. everolimus, mycophenolate mefetil, an sirolimus c. tacrolimus, prednisone, and mycophenolate mofetil d. prednisone, polyclonal antibodies, and cyclosporine

c. tacrolimus, prednisone, and mycophenolate mofetil Standard immunotherapy involves the use of 3 different immunosuppressants that act in different ways: a calcineurin inhibitor (cyelosporin, tacrolimus), a corticosteroid, and the antimetabolite mycophenolate mofetil. Although cyclosporin is still used, tacroliums is the most frequently percribed calcineurin inhibitor.

11. In a person having an acute rejection of a transplanted kidney, which of the following would help the nurse understand the course of events? (Select all that apply) a. A new transplant should be considered b. Acute rejection can be treated with OKT3 c. Acute rejection usually leads to chronic rejection d. Corticosteroids are the most successful drugs used to treat acute rejection. e. Acute rejection is common after a transplant and can be treated with drug therapy.

b,e B. Acute rejection can be treated with OKT3 E. Acute rejection is common after a transplant and can be treated with drug therapy. Rationale: Acute rejection is treatable and does not usually require a new transplant. Monoclonal antibodies such as Muromonab-CD3 (Orthoclone OKT3) are used for preventing and treating acute rejection episodes. Calcineurin inhibitors are the most effective immunosuppressants available to treat organ rejection. It is not uncommon to have at least one acute rejection episode, especially with organs from deceased donors. These episodes are usually reversible with additional immunosuppressive therapy that may include increased corticosteroid doses or polyclonal or monoclonal antibodies.

8. A 55-year-old with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is appropriate? a. "Since you are diabetic, you would not be a candidate for a heart transplant." b. "The choice of a patient for a heart transplant depends on many different factors." c. "Your heart failure has not reached the stage in which heart transplants are considered." d. "People who have heart transplants are at risk for multiple complications after surgery."

b. "The choice of a patient for a heart transplant depends on many different factors." ANS: B Indications for a heart transplant include end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patient's question. DIF: Cognitive Level: Application REF: 814

17. Currently, histocompatibility leukocyte antigen (HLA) typing can be used to : a. determine paternity and predict risk for certain diseases. b. match tissue types for transplantation and determine paternity. c. establish racial background and predict risk for certain diseases. d. predict risk for certain diseases and match tissue types for transplantation.

b. match tissue types for transplantation and determine paternity. At the current time, HLA typing is used to determine paternity and to match tissue for transplantation. As more knowledge is gain, there is a strong possibility that HLA associations with certain diseases can be specified and an individual's risk for disease identified.

12. The decision to donate one's organs or tissues can be made by person __________ death or by a person's ____________after death.

before death, a person's family after death

A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was "knocked out," but came to and "seemed okay." Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? A) Insertion of an intracranial monitoring device B) Treatment with antihypertensives C) Emergency craniotomy D) Administration of anticoagulant therapy

c

The nurse planning the care of a patient with head injuries is addressing the patient's nursing diagnosis of "sleep deprivation." What action should the nurse implement? A) Administer a benzodiazepine at bedtime each night. B) Do not disturb the patient between 2200 and 0600. C) Cluster overnight nursing activities to minimize disturbances . D) Ensure that the patient does not sleep during the day.

c

The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A) Position the patient in a high Fowler's position when in bed. B) Support the knees with a pillow when the patient is in bed. C) Perform passive ROM exercises as ordered. D) Administer NSAIDs as ordered.

c

3. After teaching a patient on immunosuppressant therapy after a kidney transplant about the posttransplant drug regimen, the nurse determines that *additional teaching* is needed when the patient says, a. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." b. "I need to be monitored closely because I have a greater chance of developing malignant tumors." c. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor." d. "The drugs are given in combination because they inhibit different aspects of transplant rejection."

c. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor." The calcineurin inhibitor will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics. DIF: Cognitive Level: Application REF: 230-232

2. When the nurse is admitting a patient who has acute rejection of an organ transplant, which of these already admitted patients will be the most appropriate roommate? a. A patient who has viral pneumonia b. A patient with second degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

c. A patient who is recovering from an anaphylactic reaction to a bee sting ANS: C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient with anaphylaxis. DIF: Cognitive Level: Application REF: 230

7. Which information about patient and donor tissue typing results for a patient who needs a kidney transplant is most important for the nurse to communicate to the health care provider? a. Patient is Rh positive and donor is Rh negative. b. Six antigen matches are present in HLA typing. c. Results of patient-donor cross matching are positive. d. Panel of reactive antibodies (PRA) percentage is low.

c. Results of patient-donor cross matching are positive. ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation, since hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable. DIF: Cognitive Level: Application REF: 229

9. When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider? a. Dry lips and oral mucous b. Crackles at both lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

c. Temperature 100.8° F (38.2° C) ANS: C Infection risk is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions, but do not indicate a need for urgent action. DIF: Cognitive Level: Application REF: 1088

1. A 21-year-old is dying after an automobile accident. The family members want to donate the patient's organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when a. the patient is flaccid and unresponsive. b. CPR is ineffective in restoring heartbeat. c. the patient is apneic and without brainstem reflexes. d. respiratory efforts cease and no apical pulse is audible.

c. the patient is apneic and without brainstem reflexes. The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead. DIF: Cognitive Level: Comprehension REF: 155

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? A) Sports-related injuries B) Acts of violence C) Injuries due to a fall D) Motor vehicle accidents

d

The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? A) Promoting adequate circulation B) Treating the child's increased ICP C) Assessing secondary brain injury D) Preserving brain homeostasis

d

14. A patient with cirrhosis asks the nurse about the possibility of a liver transplant. The best response by the nurse is: a. "liver transplants are only indicated in children with irreversible liver disease" b. "If you are interested in a transplant, you really should talk to your doctor about it. " c. "rejection is such a problem in liver transplants that it is seldom attempted in patients with cirrhosis. " d. "Cirrhosis is an indication for transplantation in some cases. Have you talked to your doctor about this? "

d. "Cirrhosis is an indication for transplantation in some cases. Have you talked to your doctor about this? " Liver transplantation is indicated for patients with cirrhosis as well as for many adults and children with other irreversible liver diseases. Although health care providers make the decisions regarding the patient's qualifications for transplant, nurses should be knowledgeable about the indications for transplantation and be able to discuss the patient's questions and concerns related to transplantation. Rejection is less of a problem in liver transplants than in kidney or heart transplantation.

10. Which of the following accurately describes rejection following transplantation? a. Hyperacute rejection can be treated with OKT3 b.Acute rejection can be treated with *sirolimus* or tacrolimus. c.Chronic rejection can be treated with tacrolimus or cyclosporine. d. Hyper-acute reaction can usually be avoided is crossmatching is done before the transplantation.

d. Hyper-acute reaction can usually be avoided is crossmatching is done before the transplantation. Correct answer: d Rationale: A positive crossmatch indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation. If transplanted, the organ would undergo hyperacute rejection.

5. A patient has a new prescription for *cyclosporine* after having a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.

d. The patient has a glass of grapefruit juice every day for breakfast. ANS: D Grapefruit juice can increase the cyclosporine to toxic levels. The patient should be taught to avoid grapefruit juice. High fluid intake will not impact cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patient's many concerns should be addressed, but these are not potentially life-threatening problems. DIF: Cognitive Level: Application REF: 230

15. The evaluation team for cardiac transplantation determines that the patient who would most benefit from a new heart is: a. a 24-year-old man with Down Syndrome who has received excellent care from parents in their 60's b. a 46-year-old single woman with a limited support system who has alcohol-induced cardiomyopathy. c. a 60-year-old man with inoperable coronary artery disease who has not been compliant with lifestyle changes and rehabilitation programs. d. a 52 -year-old woman with end-stage coronary artery disease who has limited financial resources but is emotionally stable and has strong social support.

d. a 52 -year-old woman with end-stage coronary artery disease who has limited financial resources but is emotionally stable and has strong social support. The 52 year old woman does not have any contraindications for cardiac transplantation, even though she lacks the indication of adequate financial resources. The postoperative transplant regimen is complex and rigorous , and patients who have not been compliant with other treatments or who might not have the means to understand the care would NOT be good candidates. A history of drug or alcohol abuse is usually a contraindication to the heart transplantation. (This would add rationale for why "a" is not the answer.)