Exam 1

Which is a serious side effect associated with positive end-expiratory pressure (PEEP)? 1 Lung infection 2 Ventilatory failure 3 Pulmonary embolism 4 Tension pneumothorax

4 PEEP is used to prevent the alveoli from collapsing at the end of expiration. The most serious side effect of PEEP is tension pneumothorax, in which the alveoli rupture and air accumulates in the pleura. (EAQ)

Which action will the nurse instruct a client with an endotracheal tube to perform during the time the tube is being removed? A. inhale B. exhale C. cough D. hold his/her breath

B

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. a 30 year old receiving continuous positive airway pressure (CPAP) and has intermittent wheezing B. A 40 year old receiving oxygen facemask and whose respiratory rate is 24 breaths per minute C. A 50 year old being mechanically ventilated who has tracheal deviation D. A 60 year old who was recently extubated and reports a sore throat

C this is signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock

What dietary suggestions are indicated for a patient who is in the healing phase after acute pancreatitis? Select all that apply. 1 Bland foods 2 Low-fat foods 3 Low-protein foods 4 Small, frequent meals 5 Low-carbohydrate foods

1,2,4 Patients in the healing phase after acute pancreatitis should have bland, low-fat foods and small, frequent meals. Patients should have a high, not low, carbohydrate diet and a high, not low, protein diet.

A patient admitted with a diagnosis of pancreatitis is questioning the NPO order. What statement by the nurse is most appropriate? 1 "This alleviates the pain." 2 "This reduces pancreatic enzyme secretion." 3 "This rests your stomach and decreases vomiting." 4 "We will provide IV fluid replacement with calcium."

2 The patient is kept NPO to reduce pancreatic enzyme secretion and rest the pancreas. The patient should have pain relief; however, this is not the reason for the patient's NPO status. The patient is not NPO to rest the stomach or decrease vomiting. The patient is not NPO to give IV replacement with calcium.

Which symptom of chronic pancreatitis also occurs with acute pancreatitis? 1 Ascites 2 Abdominal pain 3 Protein malabsorption 4 Loss of exocrine function

2 Abdominal pain occurs with both types of pancreatitis, although pain intensity does vary between the two. Ascites, loss of exocrine function, and protein malabsorption occur only with chronic pancreatitis.

The nurse understands that which patient is at highest risk for developing gallstones? 1 Thin female who has recently given birth 2 Obese female on hormone replacement therapy 3 Thin male with a history of coronary artery bypass grafting 4 Obese male with a history of chronic obstructive pulmonary disease

2 Both obesity and altered hormone levels increase a woman's risk for developing gallstones. Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, this woman's thin frame lessens that risk.

Which physiologic effect may indicate mild carbon monoxide poisoning? 1 Altered mental state 2 Decreased visual acuity 3 Decreased blood pressure 4 Cardiopulmonary instability

2 The physiologic effects associated with mild carbon monoxide poisoning are decreased visual acuity, slight breathlessness, decreased cerebral function, and headache. The physiological effects associated with moderate carbon monoxide poisoning are decreased blood pressure, altered mental state, and vertigo. In severe carbon monoxide poisoning, cardiopulmonary instability can be seen.

Which type of burns result in a reduction in the activation of vitamin D when exposed to sunlight? 1 Full-thickness burns 2 Partial-thickness burns 3 Deep full-thickness burns 4 Superficial-thickness burns

2 Vitamin D is formed by the action of sunlight on the cholesterol compounds present in the dermis. In partial-thickness burn injuries, there is a complete damage of the epidermis and varying depths of damage to the dermis, so there is a reduction in the activation of vitamin D. In full-thickness burn injuries, there is destruction of the entire epidermis and dermis, leaving no skin cells to repopulate. The activation of vitamin D by the skin is completely stopped, not just reduced. In deep full-thickness burn injuries, the damage extends beyond the skin, so there is no scope for activation of vitamin D through the skin. In superficial-thickness burn injuries, only the top layer of skin is damaged; the dermis is not damaged. There is not any reduction in the activation of vitamin D.

The nurse expects which changes in a patient with acute respiratory distress syndrome (ARDS)? Select all that apply. 1. Increase in lung volume 2 Expansion of lung channels 3 Reduction in surfactant activity 4 Damage to type II pneumocytes 5 Edema around terminal airways

3,4,5 ARDS occurs as a result of an acute lung injury. The injury typically happens in the alveolar-capillary membrane. As a result of the injury, surfactant is diluted by extra fluid in the lungs. Type II pneumocytes are damaged, and edema forms around terminal airways. Surfactant activity is reduced due to the damage of type II pneumocytes. The collapsed alveoli cannot exchange gases, and edema forms around terminal airways. In ARDS, lung volume is decreased and lung channels are compressed. (EAQ)

What labs should the nurse review for a patient suspected of having cholecystitis? Select all that apply. 1 Platelets 2 Hematocrit 3 Liver function 4 White blood cells 5 Alkaline phosphate

3,4,5 Liver function, white blood cells, and alkaline phosphate are often elevated in patients with cholecystitis. Hematocrit and platelets are not often abnormal, and therefore are not diagnostic.

The patient is evaluated for use of extracorporeal shockwave lithotripsy for treatment of cholelithiasis. What findings should the nurse notify the health care provider about? 1 Body mass index (BMI) of 27 2 Upper abdominal pain 3 Cholesterol-based stones 4 Poor gallbladder function

4 A patient scheduled for extracorporeal shockwave lithotripsy should have normal gallbladder function, so poor gallbladder function should be reported. A BMI of 27 indicates normal weight, which is necessary for this procedure. Upper abdominal pain is expected in a patient who has gallstones. A patient with cholesterol-based stones is an appropriate candidate for this procedure.

A patient is diagnosed with acute pancreatitis. Which test is a sensitive indicator of biliary obstruction in this disorder? 1 Serum amylase 2 Serum bilirubin 3 Alkaline phosphatase 4 Serum alanine aminotransferase

4 Serum alanine aminotransferase is a sensitive indicator of biliary obstruction in acute pancreatitis. A threefold or greater rise in concentration indicates that the diagnosis of acute biliary pancreatitis is valid. Serum bilirubin, alkaline phosphatase, and serum amylase are diagnostic tests prescribed for a patient with acute pancreatitis but do not reflect biliary obstruction.

What type of cirrhosis is caused by hepatitis C? 1 Biliary 2 Laennec's 3 Cholestatic 4 Postnecrotic

4 The hepatitis C virus causes postnecrotic cirrhosis. Laennec's cirrhosis is caused by chronic alcoholism. Biliary cirrhosis is also called cholestatic cirrhosis; it is caused by chronic biliary obstruction or autoimmune disease.

Which individual has the greatest risk for developing hepatitis A? 1 Health care worker 2 Intravenous drug user 3 Patient receiving hemodialysis 4 Person who consumes raw oysters

4 Undercooked or raw shellfish from contaminated waters and food handled by those who have not washed their hands thoroughly are at risk for hepatitis A. Intravenous drug users, those undergoing hemodialysis, and health care workers are more at risk for hepatitis B or C, which is spread by blood or body fluids.

When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team for intervention for which client? A. client treated for pulmonary embolism with IV heparin who has hemoptysis and tachy-cardia B. client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain C. client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94% C. client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs

A

A 59-year-old patient with a history of alcohol abuse spanning 15 years has been diagnosed with cirrhosis. The patient will be undergoing abdominal paracentesis today. Which assessment finding alerts the nurse that the paracentesis has been successful? A. Decrease in post-procedure weight B. No residual obtained during procedure C. Substantial decrease in blood pressure D. Immediate sensation of a need to urinate

A Weight should decrease as fluid is drained from the abdominal cavity. A substantial decrease in blood pressure can indicate shock. Residual should be obtained during the procedure. The patient should not feel a sensation or need to urinate, because a primary safety measure is to have the patient void right before the procedure to avoid injury to the bladder during the procedure.

Which clients will the nurse monitor most closely for respiratory failure? (SATA) A. a 30 year old with a c5 spinal cord injry B. a 35 year old using client controlled analgesia C. a 40 year old with acute pancreatitis D. a 50 year old experiencing cocaine intoxication E. A 55 year old with a brainstem tumor F. a 65 year old with COVID 19 pneumonia

A,B,C,E,F cocaine is a simulant which would not cause respiratory failure unless a stroke ensued

What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear? A. humidifying the oxygen source B. suctioning the tracheostomy tube C. increasing the percentage of oxygen D. remove the inner cannula of the tracheostomy

B The best action by the nurse is to suction the tracheostomy tube. This will likely result in clear lung sounds and lower peak pressure

For which problems with the nurse specifically assess when the low-pressure alarm of a client's mechanical ventilator sounds (SATA) A. ventilator tubing is under the client B. cuff leak in the endotracheal or tracheostomy tube C. client is not breathing D. mucous plugs are in the endotracheal tube E. leak in the ventilator tubing circuit F. client is attempting to breath against the ventilator

B,C, E

Which ventilator mode does the nurse expect will be set for a client with a tracheostomy who is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths? A. assist-control (AC) ventilation B. bi-level positive airway pressure (BiPAP) C. Continuous positive airway pressure (CPAP) D. synchronized intermittent ventilation (SIMV)

D SIMV is a vent mode in which volume and ventilation rate are preset; it allows spontaneous breathing at the patient's own rate and tidal volume between the ventilator breaths to coordinate breathing between the vent and the client

Which action has the highest priority for the nurse to take to prevent harm for a client being mechanically ventilated with 100% oxygen for the past 24 hours who now has new-onset crackles, decreased breath sounds, and a PaO2 level of 95 mm Hg? A. assessing cognition B. preparing to suction the client C. placing the client in the prone position D. collaborating with the pulmonary health care provider to lower the FiO2 level

D prompt identification and correction of the underlying disease process and potential oxygen toxicity may require delivery of a lower FiO2.

Which of the following is a normal age related change in relation to gas exchange for a 6 month old infant? A. Obligate nasal breather B. Decreased surfactant C. Weaker intercostal muscles D. Decreased Hgb

D The fetal hemoglobin concentration in blood decreases after birth by approximately 3 percent per week and is generally less than 2 to 3 percent of the total hemoglobin by 6 months of age. (Citation: Esan AJ. Hematological differences in newborn and aging: a review study. Hematol Transfus Int J. 2016;3(3):178-190. DOI: 10.15406/htij.2016.03.00067) (lecture)

The chest tube of a client who is 12 hours postoperative from a lobectomy separates from the drainage system. What is the nurse's best first action? A. Immediately call the surgeon or rapid response team B. Notify respiratory therapy to set up a new drainage system C. Cover the insertion site with a sterile occlusive dressing and tape down on three sides D. place the end of the disconnected tube into a container of sterile water positioned below the chest

D. place the end of the disconnected tube into a container of sterile water positioned below the chest (Iggy p593)

Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)? 1 Major burn 2 Minor burn 3 Severe burn 4 Moderate burn

Deep partial-thickness burns affecting 15% to 25% TBSA are classified as moderate burns. Partial-thickness burns affecting more than 25% of TBSA are classified as major burns. Deep partial-thickness burns affecting less than 15% of TBSA are considered minor burns. Burns are categorized as three types: major, minor, and moderate. There is no "severe" burn category.

Which action will the nurse take first while caring for a client being mechanically ventilated when the high-pressure alarm sounds? A. comparing the ventilator settings with the prescribed settings B. turning off the alarm then assess the need for suctioning C. auscultating the client's breath sounds D. notify the respiratory therapist

c always assess pt first, then trouble shoot the ventilator

A client diagnosed with cirrhosis is experiencing worsening confusion. What intervention is a priority in the plan of care? A. limit sodium intake B. restrict fluids C. reduce protein intake D. measure abdominal girth E. reorient the client

C. hepatic encephalopathy is related to excess ammonia

Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? A. Decreased skin turgor B. Decreased pulse pressure C. Decreased core body temperature D. Decreased urine specific gravity

D (Iggy 495)

Which does the nurse recognize as the primary reason for a higher incidence of liver cancer in the United States? A. Incidence of hepatitis C B. Incidence of HIV infection C. Incidence of illicit drug use D. Incidence of hepatitis A

ANS: A In the United States and worldwide, the incidence of liver cancer is increasing because there is an increase in cases of hepatitis C (HCV).

normal AST levels what would high levels indicate?

0-35 u/L high levels indicate liver damage

normal value for serum bilirubin what could high levels indicate?

0.3-1 mg/dL high levels could indicate chronic cholecystitis or acute pancreatitis

When performing an abdominal assessment on a patient diagnosed with pancreatitis, the nurse notes gray-blue discoloration around the periumbilical area, a dull sound on percussion, and normal bowel sounds. What action by the nurse is priority? 1 Document the findings 2 Prepare the patient for the operating room 3 Contact the health care provider immediately 4 Obtain a stat hemoglobin and hematocrit level

1 A blue discoloration around the periumbilical area is a normal finding in a patient with acute pancreatitis. A dull sound on percussion may be caused from pancreatic ascites. The findings should be documented. The patient does not need to go to the operating room. The health care provider does not need to be contacted immediately. Checking the hemoglobin and hematocrit level is not indicated.

While reviewing the laboratory profile of a burn patient in the resuscitation phase, the nurse finds the patient's glucose level to be 120 mg/dL. Which is the most likely cause for this? 1 Stress response 2 Fluid volume loss 3 Tissue destruction 4 Reabsorption of chloride in urine

1 A stress response as seen following a burn injury may cause an elevation in the blood glucose level. Fluid volume loss may cause dehydration and impaired electrolyte balance, but will not affect glucose levels. Tissue destruction may result in hyperkalemia, not hyperglycemia. Reabsorption of chloride in the urine will result in hypochloremia, not hyperglycemia.

What laboratory finding signifies an immune response to liver disease? 1 Elevated serum globulin 2 Elevated serum ammonia 3 Decreased serum albumin 4 Decreased serum total protein

1 An increase in the serum globulin level indicates an immune response to liver disease. A decrease in serum total protein signifies chronic liver disease, and a decrease in serum albumin signifies severe liver disease. The serum ammonia level is elevated in advanced liver disease or portal-systemic encephalopathy because the liver is unable to detoxify protein byproducts.

In caring for a patient who has undergone paracentesis, which changes in the patient's status should be promptly reported to the provider? 1 Decreased blood pressure, increased heart rate 2 Tachypnea, diaphoresis, increased blood pressure 3 Increased blood pressure, increased respiratory rate 4 Increased respiratory rate, increased apical pulse, pallor

1 Decreased blood pressure and increased heart rate are indicative of shock. Increased blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea, and diaphoresis are all indicative of anxiety on the patient's part.

The nurse is reviewing the diagnostic test results for a patient with hepatitis. Which elevated test result does the nurse correlate to the presence of jaundice? 1 Bilirubin 2 Blood urea nitrogen (BUN) 3 Alanine aminotransferase (ALT) 4 Aspartate aminotransferase (AST)

1 Elevation of the bilirubin level correlates to yellow stain of the skin and sclera secondary to biliary obstruction and inflammation. BUN is a measure of renal function. AST and ALT are enzymes released in response to liver inflammation, but do not correlate to jaundice.

An escharotomy must be performed in a patient admitted for burns. Which statement accurately describes this procedure? 1 An incision is made through the burn eschar. 2 The procedure is performed in the surgical suite. 3 Anesthesia is administered to the patient for pain. 4 Analgesia is not administered with this procedure.

1 Escharotomy is a surgical procedure that is performed to treat inadequate tissue perfusion in the patient with severe burns. In this procedure, an incision is made through the burn eschar. It helps to relieve the pressure caused due to fluid accumulation near the chest and improves circulation. It is not necessary to administer anesthesia to the patient, as the nerve endings are destroyed due to the injury. The patient is given sedation and analgesia to reduce anxiety. Although escharotomy is a surgical procedure, it is often performed in a treatment room.

Which assessment finding is consistent with a diagnosis of viral hepatitis? 1 Icteric skin 2 Dark-brown stool 3 Light-colored urine 4 Left upper quadrant tenderness

1 Findings in viral hepatitis include fever, jaundice or icterus, itching, clay-colored stool, dark urine, right upper quadrant tenderness, and nausea.

When managing the care of a patient with a major full-thickness burn, when would the nurse begin to see fluid shifts resulting in edema? 1 Within 12 hours 2 After 24 hours 3 After 30 hours 4 After 36 hours

1 Fluid shifts occur after initial vasoconstriction; the leakage of fluid and electrolytes from the vascular spaces leads to extensive edema. Fluid shift with extensive weight gain occurs within the first 12 hours after the burn and continues for 24 to 36 hours.

When is grafting required in the treatment of burn injuries? 1 When there is absence of skin cells 2 When there is damage to the blood vessels 3 When there is exposure to the nerve endings 4 When the dead tissue sticks to the lower tissue layers

1 Grafting is usually required in deep full-thickness and full-thickness burn injuries. In these injuries, there is full destruction of the entire epidermis and dermis, leaving no skin cells to repopulate. Therefore, these wounds do not regrow and the area of injury is not closed by wound contraction. Damage to the blood vessels in superficial-thickness wounds leads to blister formation. Exposure of nerve endings for stimulation results in intensifying the pain. Sticking of the dead tissue to the lower tissue layers will lead to eschar formation.

Which type of burn injuries includes an escharotomy as a part of the treatment plan? 1 Full-thickness wounds 2 Deep full-thickness wounds 3 Deep partial-thickness wounds 4 Superficial partial-thickness wounds

1 In a patient that sustained full-thickness wound, hard, leathery dead tissue is present. This forms from the coagulated particles of the destroyed skin, which is called eschar. These particles stick to the lower tissue layer, affecting the healing of the injury. If severe edema is present under the eschar, it can result in decreased blood flow, making chest movement difficult for breathing. This can be solved by performing an escharotomy. This surgical procedure relieves pressure, allows for normal blood flow, and facilitates breathing. In deep full-thickness wounds, the damage extends beyond the skin to muscles and bones. Thus, grafting can be used as a part of treatment. In deep partial-thickness wounds, eschar is formed but it is soft and dry, which makes removal easy. In superficial partial-thickness wounds, there is no eschar.

A patient scheduled for a cholecystectomy because of gallstones causing cholecystitis reports a pain level of 4 on a 0-to-10 pain scale. Which analgesic medication does the nurse anticipate will be prescribed for the patient? 1 Ketorolac 2 Morphine 3 Meperidine 4 Hydromorphone

1 Ketorolac may be used for mild to moderate pain. Acute biliary pain requires opioid analgesia, such as morphine or hydromorphone. In the past, meperidine was the drug of choice for acute biliary pain because it was thought to cause fewer spasms of the sphincter of Oddi, which blocks bile flow. However, this drug breaks down into a toxic metabolite and can cause seizures, especially in older adults. All opioids may cause some degree of sphincter spasm.

The nurse asks a patient with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? 1 Asterixis 2 Kehr's sign 3 Hyperreflexia 4 Positive Babinski's sign

1 Liver flap or asterixis is related to increased serum ammonia levels—the dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Babinski's sign is positive when the sole of the foot is stroked, the great toe points up, and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep-breathing, and is referred to the right shoulder.

The nurse is caring for a patient who has liver trauma as a result of a motor vehicle crash. What sign/symptom, if present in the patient, would prompt the nurse to suspect internal hemorrhage and hypovolemic shock? 1 Tachypnea 2 Bradycardia 3 Hot, dry skin 4 Hypertension

1 Liver is a highly vascular organ. Hepatic trauma can cause massive blood loss. Tachypnea is an indicator of hemorrhage and hypovolemic shock in patients with liver trauma. Other indicators include hypotension rather than hypertension, and tachycardia rather than bradycardia. The skin is cool and clammy with excessive sweating.

What type of burn injury may require the nurse to remove smoldering clothing and metal objects that are close to the patient's body? 1 Flame burns 2 Chemical burns 3 Electrical burns 4 Radiation burns

1 Metal objects are good conductors of electricity. A flame burn is a contact burn. Therefore, any clothing or metal objects in contact with the body must be removed to prevent further injury. Chemical burns are caused when specific chemicals are used; these burns can be managed by using suitable neutralizing agents. Electrical burns are caused by an electrical current that obstructs respiration. Radiation burns are caused by exposure to certain radiations.

The patient has severe biliary obstruction. What type of surgery does the nurse anticipate this patient requiring in order to explore the ducts for patency? 1 Traditional cholecystectomy 2 Transhepatic biliary catheter 3 Laparoscopic cholecystectomy 4 Natural orifice transluminal endoscopic surgery

1 Patients with severe biliary obstruction whose ducts will need to be explored will need a traditional cholecystectomy. A transhepatic biliary catheter placement is not a surgical procedure to treat cholecystectomy. A laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery will not provide visualization of the ducts.

When caring for a patient with hepatic encephalopathy, which patient condition would cause the nurse to question the use of neomycin? 1 Kidney failure 2 Fetor hepaticus 3 Refractory ascites 4 Paracentesis scheduled in 2 hours

1 The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by a patient with kidney failure. Fetor hepaticus causes an ammonia smell in the breath when the serum ammonia level is elevated; neomycin is used to decrease this level. Cirrhosis and hepatic failure can cause refractory ascites. This condition alone does not present a contraindication for neomycin use. The patient may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

Which method is used in assessing the measurement of burns in a patient whose weight and height are in proportion? 1 Body area is divided into multiples of 9% 2 Body area is divided into multiples of 5% 3 Body area is divided into multiples of 12% 4 Body area is divided into multiples of 20%

1 The rule of nines helps in assessing the size of burns. It involves estimating the total body surface area in a normal adult patient whose weight and height are in proportion. According to this rule, the body surface area must be divided into multiples of 9%.

Which degree of burn may result in reduced excretory ability of the skin? 1 Full-thickness wound 2 Partial-thickness wound 3 Superficial-thickness wound 4 Deep partial-thickness wound

1 The skin excretes through sweating. In full-thickness burns, the sweat glands are destroyed and the skin has a reduced ability to excrete. Partial-thickness wounds may involve the loss of the entire epidermis and varying depths of dermis; it does not totally reduce the excretory function of the skin. Superficial-thickness wounds have the least amount of damage because the epidermis is the only part of the skin that is injured. Deep partial-thickness wounds also do not reduce the excretory ability of the skin because there is no dermal damage.

When assessing a patient for possible liver dysfunction, the nurse notices round, pinpoint, red-purple lesions on the patient's skin. What term should the nurse use to document such lesions? 1 Petechiae 2 Ecchymosis 3 Telangiectases 4 Spider angioma

1 The term petechiae is used for round, pinpoint, red-purple lesions. Ecchymoses are large purple, blue, or yellow patches. Telangiectases and spider angioma are terms used for vascular lesions with a red center and radiating branches.

Which patient characteristics are risk factors for cholelithiasis? Select all that apply. 1 Aging 2 Obesity 3 Depression 4 Diabetes mellitus 5 Vitamin deficiency

1,2,4 The risk for developing gallstones increases with age. Obesity increases the risk for cholelithias is due to impaired fat metabolism or increased cholesterol. Diabetes mellitus increases the chances of cholelithiasis due to higher levels of fatty acids. Neither depression nor vitamin deficiency cause cholelithiasis; they do not interfere with bile production and storage.

The nurse is caring for a patient with cirrhosis. What factors may lead to hepatic encephalopathy in the patient? Select all that apply. 1 Constipation 2 Low-protein diet 3 Decreased fluid volume 4 Gastrointestinal bleeding 5 Increased serum potassium

1,3,4 Decreased fluid volume, constipation, and gastrointestinal bleeding may cause hepatic encephalopathy in patients with cirrhosis. Other causes include a high-protein diet and decreased serum potassium levels.

When assessing a patient with hepatitis B, the nurse anticipates which assessment findings? Select all that apply. 1 Itching 2 Brown stool 3 Tea-colored urine 4 Recent influenza infection 5 Right upper quadrant tenderness

1,3,5 The urine may be brown, tea-, or cola-colored in patients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored.

When caring for a patient with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? Select all that apply. 1 Icterus of skin 2 Currant jelly stool 3 Swollen abdomen 4 Elevated magnesium 5 Elevated amylase level 6 Prolonged partial thromboplastin time (PTT)

1,3,6 The liver produces clotting factors; when it is damaged, prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The patient with cirrhosis may develop ascites, or fluid in the abdominal cavity. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. Cirrhosis is consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase; amylase is typically elevated in pancreatitis.

The nurse is preparing to administer the prescribed dose of pancrelipase to a patient with chronic pancreatitis. What pancreatic enzymes make up this medication? Select all that apply. 1 Lipase 2 Trypsin 3 Elastase 4 Amylase 5 Protease

1,4,5 Pancrelipase provides the enzymes that the body is unable to produce because of chronic pancreatitis. It is a combination of the enzymes lipase, amylase, and protease in different concentrations. It does not contain trypsin and elastase.

normal value for serum ammonia what does a high value indicate?

10-80mcg/dL high levels indicate liver damage

A patient who was rescued from an explosion is provided fluid resuscitation. Which factor should be assessed in the patient after providing fluid resuscitation? 1 Hemoglobin levels 2 Serum sodium levels 3 Serum calcium levels 4 Alanine aminotransferase

2 A patient who was rescued from an explosion has a high risk of losing kidney function. Protein and myoglobin released into the blood from muscle trauma (rhabdomyolysis) can accumulate in the kidneys, impede renal blood flow, and cause renal failure, so fluid resuscitation must be provided to maintain a 30 to 50 mL per hour urine output. To assess kidney function after providing fluid resuscitation, serum sodium and creatinine levels and urine specific gravity should be monitored hourly. Monitoring renal function is also important to avoid fluid overload. Hemoglobin, alanine aminotransferase, and serum calcium levels should also be monitored, but these are not indicators of kidney function which is this patient's priority concern.

A patient with burns who was admitted to the hospital 3 days ago develops paralytic ileus. Which pathophysiological phenomenon may be the cause of the patient's condition? 1 Increased secretion of cortisol 2 Increased secretion of epinephrine 3 Increased secretion of aldosterone 4 Increased secretion of catecholamines

2 The sympathetic nervous system responds to stress by increasing the secretion of epinephrine. This inhibits the gastrointestinal motility and leads to a reduction in the blood flow to the gastrointestinal tract. Peristalsis may be reduced, which may lead to a paralytic ileus. Severe burn injury will lead to increased secretions of cortisol, aldosterone, and catecholamines. These hormones may increase the metabolism in the body, thus increasing the needs of oxygen and calories.

A patient with a burn injury due to a house fire is admitted to the burn unit. The patient's family asks the nurse why the patient received a tetanus toxoid injection on admission. What is the nurse's best response to the patient's family member? 1 "The last tetanus injection was less than 5 years ago." 2 "Burn wound conditions promote the growth of Clostridium tetani." 3 "The wood in the fire had many nails, which penetrated the skin." 4 "The injection was prescribed to prevent infection from pseudomonas."

2 Burn wound conditions promote the growth of Clostridium tetani, and all burn patients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the patient is admitted to the hospital. Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent pseudomonas infection.

Which topical agent is typically used on a burn wound for rapid debridement? 1 Penciclovir 2 Collagenase 3 Polymyxin B 4 Iodine tincture

2 Collagenase is a topical agent that can be used for rapid wound debridement. Iodine tincture is an antiseptic drug used to reduce secondary infections. Polymyxin B is a drug used to prevent infection. Penciclovir is an antiviral medication used to treat viral infections.

In acute pancreatitis, what does elevated serum lipase indicate? 1 Inflammation 2 Pancreatic cell injury 3 Hepatobiliary obstruction 4 Hepatobiliary involvement

2 Elevated serum lipase is caused by pancreatic cell injury. An elevated leukocyte count is indicative of the inflammatory response. The hepatobiliary obstructive process causes elevated bilirubin. Hepatobiliary involvement causes elevated alanine aminotransferase (ALT) and elevated aspartate aminotransferase (AST).

Which of the following skin grafts are obtained from human cadavers? 1 Porcine 2 Allograft 3 Xenograft 4 Heterograft

2 Homografts, also called allografts, are human skin obtained from a cadaver and provided through a skin bank. Heterografts, also called xenografts, are skin obtained from another species. Pigskin (porcine) is the most common heterograft and is compatible with human skin.

Which type of burn injuries includes a fasciotomy as part of the treatment plan? 1 Superficial wounds 2 Full-thickness wounds 3 Deep partial-thickness wounds 4 Superficial partial-thickness wounds

2 In patients with full-thickness wounds, edema is severe. Edema formed under the eschar may decrease blood flow to the injured site. The blood flow to the injured site can be increased by making an incision in the fascia, known as a fasciotomy. Superficial wounds damage only the epidermis with only mild edema. Deep partial-thickness wounds extend their damage to deeper layers of dermis; in this situation, few healthy skin cells remain and are able to repopulate. Superficial partial-thickness wounds cause damage to the upper third of the dermis layer, leaving a good blood supply.

Which factor is considered a risk factor in the development of cholelithiasis? 1 Anemia 2 Pregnancy 3 Less than age 40 years 4 Low body mass index (BMI)

2 In pregnancy, hormone levels (progesterone and estrogen) are altered, which delays muscular contraction of the gallbladder and decreases the rate of bile emptying, thus increasing the risk for cholelithiasis. Similarly, hormonal changes and hormonal replacement therapy make women over 40 years, not under, more susceptible to the development of cholelithiasis. Obese women, not those with a low BMI, are at a high risk of developing cholelithiasis because of impaired fat metabolism and increased cholesterol. Anemia is not associated with the development of gallstones.

The health care provider has ordered a blood transfusion for a female patient with serious electrical burns. What hematocrit level reflects the need for transfusion when symptoms of hypoxia are present? 1 25% 2 18% 3 40% 4 36%

2 Patients who have suffered severe burns due to electrical injury may have impaired kidney function due to an imbalance of fluids and electrolytes. This causes hemodilution and lowers the hematocrit value. Blood transfusion is required when the hematocrit value is less than 20% to 25% and the patient has manifestations of hypoxia. The hematocrit value for a normal adult is 40% in females and 45% in males, so a hematocrit value of 40% is considered normal. A value of 36% is not low enough to warrant blood transfusion.

A patient with cholecystitis has jaundice and icterus. These signs are typical of which type of cholecystitis? 1 Acute 2 Chronic 3 Calculous 4 Acalculous

2 Patients with chronic cholecystitis are more likely to have jaundice and icterus caused by obstruction of bile flow, causing increased circulating levels of bilirubin. Patients with acute cholecystitis present with abdominal pain. Acalculous cholecystitis and calculous cholecystitis are both types of acute cholecystitis.

Which is considered a late complication of burn injuries? 1 Sepsis 2 Scarring 3 Protein loss 4 Fluid imbalance

2 Scarring is a part of the healing process; this involves the replacement of the normal tissue by fibrous tissue after the wound is healed. Scarring occurs as a late complication after the burn injury is healed. Sepsis is not a late complication of burn injury; it is caused by bacteria worsening the tissue destruction in a burn injury. Protein loss occurs because of fluid and electrolyte imbalance; it is an early complication. Fluid imbalance is not considered a late complication.

Which activity by the nurse will best relieve symptoms associated with ascites? 1 Administering oxygen 2 Elevating the head of the bed 3 Administering intravenous fluids 4 Monitoring serum albumin levels

2 The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath. The patient may need oxygen, but first the nurse should raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring will detect anticipated decreased serum albumin levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

Which anatomical structures are absent in a histological section of the epidermis? 1 Hair follicles 2 Blood vessels 3 Sweat glands 4 Sebaceous glands

2 The epidermis is the outermost layer of the skin, made up mostly of scalelike cells called squamous cells. The epidermis has no blood vessels, and nutrients must diffuse from the second layer of the skin. Hair follicles, sweat glands, and sebaceous glands are the dermal appendages that originate at the dermis and extend to the epidermis.

The nurse is caring for a patient with chronic pancreatitis. What assessment findings are related to this disease process? Select all that apply. 1 Diarrhea 2 Jaundice 3 Polydipsia 4 Polyphagia 5 Weight gain

2,3,4 Jaundice, polydipsia, and polyphagia are manifestations observed in chronic pancreatitis. Jaundice occurs because of chronic inflammation in the biliary tract; bile cannot drain into the small intestines. Excessive thirst (polydipsia) and an increased appetite (polyphagia) occur because the patient has chronic organ dysfunction and develops diabetes mellitus (of which both symptoms are common). Diarrhea is not a symptom of chronic pancreatitis. Weight loss occurs in chronic pancreatitis.

Which factors increase the risk of developing pancreatic cancer? Select all that apply. 1 Aging 2 Cirrhosis 3 Smoking 4 Vitamin deficiency 5 Chronic pancreatitis

2,3,5 Pancreatic cancer is an abnormal growth in the pancreas. Cirrhosis, cigarette smoking, and chronic pancreatitis cause chronic irritation of the pancreatic tissue, increasing the risk for pancreatic cancer. Aging and vitamin deficiencies are not risk factors associated with pancreatic cancer.

What medications are administered to a patient with acute pancreatitis to decrease gastric acid secretion? Select all that apply. 1 Imipenem 2 Ranitidine 3 Meperidine 4 Omeprazole 5 Ciprofloxacin

2,4 Ranitidine is a histamine receptor antagonist, and omeprazole is a proton pump inhibitor. Both medications help decrease gastric acid secretion. Imipenem and ciprofloxacin are antibiotics. Meperidine is an opiate analgesic.

Which symptoms present in a patient with acute pancreatitis indicate complications? Select all that apply. 1 Vertigo 2 Jaundice 3 Depression 4 Darkened urine 5 Clay-colored stools

2,4,5 Acute pancreatitis occurs because of an inflammation of the pancreas. The enzymes released by the pancreas cause autolysis of the pancreatic tissue. Jaundice, darkened urine, and clay-colored stools indicate complications of acute pancreatitis. Jaundice occurs because of an obstruction in the biliary tract, where bile cannot be absorbed into the gastrointestinal tract. Bile salts accumulate in the skin, causing a yellowish discoloration. An increase in serum bilirubin due to the biliary obstruction causes darkened urine. Stools become clay-colored because of an obstruction in the biliary tract. Vertigo and depression are not symptoms of acute pancreatitis.

The nurse is caring for a patient who has been admitted multiple times for pancreatitis. The patient has inflammation and fibrosis of the tissue and diminished pancreatic function. What assessment is priority for this patient? 1 Nicotine use 2 Family support 3 Alcohol consumption 4 Adherence to prescribed medication regimen

3 Alcoholism is a common risk factor for pancreatitis. Nicotine use assessment is not necessary. Family support is important but is not priority. Adherence to the prescribed medication regimen is important but not priority.

What imaging will provide the most reliable diagnosis of acute pancreatitis? 1 Chest x-ray 2 Abdominal ultrasound 3 Contrast-enhanced computed tomography 4 Endoscopic retrograde cholangiopancreatography (ERCP)

3 Contrast-enhanced computed tomography provides more reliable images and diagnosis of acute pancreatitis. A chest x-ray will show elevation but is not diagnostic. An abdominal ultrasound is not helpful to view the whole pancreas. An ERCP is better for diagnosing pancreatic stones, not acute pancreatitis.

A patient is suspected of having deep muscle burn injuries. Which reason would the nurse identify as a cause of burn injury? 1 Dry heat 2 Chemical 3 Electrical 4 Moist heat

3 Deep muscle injuries may be present even if the superficial muscles appear normal or uninjured. Muscle injuries can occur in the case of electrical burns. Dry heat injuries can damage the superficial layer of the skin. Chemical injuries can damage the epithelial tissues. Moist heat injuries can damage the superficial layer and tissues.

Which type of burn injury is caused by an open flame? 1 Scald 2 Contact 3 Dry heat 4 Electrical

3 Dry heat injuries are caused by an open flame. Moist heat injuries are caused by hot liquids or steam, which results in scalding. Electrical injuries are burns occurring when electricity enters the body. Contact burns occur when a hot surface contacts the skin.

A patient is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the patient? 1 Topical 2 Sublingual 3 Intravenous 4 Intramuscular

3 During the resuscitation phase, the intravenous route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the patient in the resuscitation phase of burn injury.

Which type of injury is called a "grand masquerader" of burns? 1 Dry heat injury 2 Chemical injury 3 Electrical injury 4 Radiation injury

3 Electrical injuries are burns that occur when electrical current enters the body. These injuries are known as "grand masquerader" of burns, because the surface injuries may look small, but the associated internal injuries can be extensive. Open flame in house fires and explosions cause dry heat injuries; skin tissue is damaged in a dry heat injury. Chemical injuries mostly occur in a home setting or in industries. Injury occurs directly to the tissues by causing liquefaction of skin and its proteins. Radiation injuries occur when people are exposed to large doses of radiation, but this rarely causes extensive skin damage.

Which part of the skin helps in the healing process after a burn injury? 1 Epidermis 2 Sweat glands 3 Epithelial cells 4 Sebaceous glands

3 Epithelial cells present in the dermis layer of the skin are responsible for regrowth of the skin after a burn injury. The epidermis is the outermost layer of the skin, consisting of dermal appendages such as sweat glands, sebaceous glands, and hair follicles, which extend into the epidermis layer. Sweat glands and sebaceous glands are the dermal appendages that are present in the dermis layer and extend to the outer layer of the skin.

Which type of burn shows desquamation 2 to 3 days after the injury? 1 Deep full-thickness wound 2 Deep partial-thickness wound 3 Superficial full-thickness wound 4 Superficial partial-thickness wound

3 In superficial full-thickness wounds, desquamation occurs 2 to 3 days after the injury. The area heals rapidly in 3 to 6 days without a scar or other complications. In deep full-thickness wounds, the destruction of the entire epidermis and dermis occurs, leaving no skin cells to repopulate. Deep partial-thickness wounds extend deep into the skin dermis and fewer healthy cells remain. In superficial partial-thickness wounds, injury occurs to the upper third of the dermis, leaving a good blood supply. These wounds are pink, moist, and blanch when pressure is applied.

Which physiological change will result in loss of function from contracture formation in a 65-year-old patient with burn injuries who is admitted to the hospital? 1 Thinner skin 2 Reduced immunity 3 Slower healing time 4 Pre-existing disorder

3 Slower healing time in older adults can result in loss of function from contracture formation and scar tissue. Thinner skin increases the depth of burn injury in older adults. Reduced immunity increases the risk of infection in older adults. A medical condition present prior to the burn injury compromises vital organ functioning and can interfere with fluid resuscitation efforts or other treatments.

Which part of the skin varies in depth in the human body? 1 Dermis 2 Epidermis 3 Dermal appendages 4 Subcutaneous tissue

3 The dermal appendages such as sweat glands, oil glands, and hair follicles vary in depth in different body areas. The dermis is the second most layer of the skin, which is thicker than the epidermis. It is made up of collagen, fibrous connective tissue, and elastic fibers. The epidermis is the outermost layer of the skin, which is thinner than the dermis and contains no blood vessels. Subcutaneous tissues do not vary in depth in the human body.

Which alteration observed in a patient rescued from a fire indicates pulmonary injury? 1 Reporting dizziness 2 Coughing with sputum 3 Inability to swallow fluids 4 Exhaling through the mouth

3 The patient who has been rescued from a fire may have pulmonary injury due to inhalation of carbon monoxide. Pulmonary injury is characterized by difficulty in swallowing and a brassy cough. Exhaling through the mouth is not an indication of pulmonary injury. Even in deep breathing or in congestion, patients exhale through the mouth. The patient may have dizziness due to an imbalance in body fluids and electrolytes. Carbonaceous sputum indicates pulmonary injury or airway obstruction. Cough with sputum can be seen with infections or chronic obstructive pulmonary disorder; it does not indicate pulmonary injury.

The patient recently diagnosed with acute pancreatitis complains of severe pain despite intravenous narcotic pain medication. Into which position should the nurse assist the patient in order to help decrease pain? 1 Prone 2 Supine 3 Side lying 4 High Fowler's

3 The side-lying position may decrease the abdominal pain of pancreatitis. Prone, supine, and high Fowler's positions are not indicated to decrease pain in pancreatitis.

What is the characteristic of a burn caused by brief contact with a hot plate? 1 Severe edema 2 Red-white in color 3 Soft and dry eschar 4 Heals in about 2 weeks

4 Burns caused due to brief contact with hot objects like a hot plate are categorized as superficial partial thickness. The healing time for superficial partial thickness burns is about 2 weeks. They appear pink to red in color, rather than red to white, due to minor vasoconstriction. Mild to moderate edema is seen in superficial partial thickness burns. Eschar is not formed in superficial partial thickness burns; it is seen in deeper, more severe burns.

Which of the following factors may be associated with the development of cholelithiasis? Select all that apply. 1 Smoking 2 Weight loss 3 Nutrition habits 4 Sedentary lifestyle 5 Mexican-American populations

3,4,5 A familial or genetic tendency appears to play a role in the cholelithiasis, but this may be partially related to familial nutrition habits (excessive dietary cholesterol intake) and sedentary lifestyles. The highest frequency of gallstone production lies among the American-Indian and Mexican-American populations. Development of gallstones is not related to smoking or normal weight loss.

Which description of minor burn wound care defines open technique? 1 The wound is cleaned with hot water. 2 The wound is cleaned every 48 to 72 hours. 3 The medication is applied without the use of cotton. 4 The medication is applied on the burn without the dressing

4

Which finding is expected in a patient who has a liver function abnormality? 1 Increased white blood cell (WBC) count 2 Decreased level of lactate dehydrogenase 3 Decreased level of aspartate aminotransferase 4 Increase in serum levels of alkaline phosphatase

4 Alkaline phosphatase is an enzyme found in the liver, kidneys, and bones. An increase in serum levels of alkaline phosphatase indicates a liver function abnormality. An increased level of WBCs indicates inflammation or infection. When the liver is not functioning normally, the level of lactate dehydrogenase and aspartate aminotransferase are increased, not decreased.

A nurse is assessing a patient who presents with severe abdominal pain radiating at times to the shoulder. The nurse notes the patient's skin and sclera are yellow in appearance. The patient reports a sedentary lifestyle and experiences rebound tenderness when tested for Blumberg sign. What does the nurse suspect? 1 The patient has chronic cholecystitis because Blumberg sign is present in this form of the disease. 2 The patient has acute cholecystitis because Blumberg sign is present in this form of the disease. 3 The patient has acute cholecystitis because jaundice and icterus are common in this form of the disease. 4 The patient has chronic cholecystitis because jaundice and icterus are common in this form of the disease.

4 Based on the provided information, it is most likely that the patient has chronic cholecystitis. Blumberg sign is present in both forms of the disease, so this information cannot help the nurse determine whether the patient has acute or chronic cholecystitis. The yellow discoloration of the skin (jaundice) and sclera (icterus) are most commonly seen in patients with chronic cholecystitis than in patients with the acute form of the disease.

Why do blisters not form in deep partial-thickness wounds? 1 Due to the leakage of large amounts of plasma 2 Due to the destruction of entire epidermis and dermis layers 3 Due to the thick dead tissue particles that stick to the tissue layers 4 Due to the thick dead tissue layer which sticks to the underlying dermis

4 Blister formation is absent in deep partial-thickness wounds due to the dead tissue layer, which is thick, sticks to the underlying dermis, and does not readily lift off the surface. Leakage of large amounts of plasma by small blood vessels present in the lower layer of dermis results in blister formation. Destruction of the entire epidermal and dermal layers is observed only during full-thickness wounds. Hard, dry, and leathery eschar that forms from coagulated particles of destroyed skin sticks to the tissue layers, making wound healing difficult in full-thickness wounds.

Which type of burn injury can convert to a deeper injury due to tissue hypoxia? 1 Superficial wounds 2 Full-thickness wounds 3 Deep full-thickness wounds 4 Deep partial-thickness wounds

4 Deep partial-thickness wounds affect the deeper layers of dermis, with only a few healthy skin cells remaining in the dermis layer. Blood supply to the injured area can be decreased through infection, hypoxia, or ischemia, resulting in more damage of the tissue; this can convert deep partial-thickness wounds to full-thickness wounds. Superficial wounds cause minimal damage to the skin, affecting the epidermal layer of the skin. Full-thickness wounds cause destruction of the entire epidermis and dermis. Deep full-thickness wound damage extends even deeper exposing the muscles and bones.

Which burn injury is characterized by desquamation? 1 Full-thickness wound 2 Partial-thickness wound 3 Deep full-thickness wound 4 Superficial-thickness wound

4 Desquamation, or peeling of dead skin, is usually seen in a superficial-thickness wound, 2 to 3 days after the burn. These wounds heal within 3 to 6 days and do not leave a scar behind. A full-thickness wound generally blanches (lightens) on applying pressure. Dry, leathery eschar formation is observed in a partial-thickness wound. In a deep full-thickness wound, the affected area is blackened and depressed.

Which factor differentiates full-thickness wounds from deep full-thickness wounds? 1 Intensity of pain 2 Eschar formation 3 Blisters formation 4 Severity of edema

4 Edema is the major difference between full-thickness wounds and deep full-thickness burn injuries. In patients with deep full-thickness burn injuries, edema is completely absent. The presence of severe edema in patients is an indication of full-thickness wounds. Pain is absent in deep full-thickness wounds, and it may be present or absent in full-thickness burn injuries. Eschar formation is present in both types of injuries, and these are hard and elastic. Blisters are absent in both types of burn injuries.

A patient reports fever, yellowing of the skin and eyes, clay-colored stools, and dark urine. The nurse suspects further testing will reveal which condition? 1 Peritonitis 2 Malnutrition 3 Vitamin deficiency 4 Chronic cholecystitis

4 Fever, yellowing of the skin and eyes, clay-colored stools, and dark urine are symptoms of chronic cholecystitis. These symptoms occur when repeated episodes of cystic duct obstruction cause chronic inflammation. Peritonitis is an infection of the peritoneal cavity in which the patient presents with a hard, distended abdomen. Patients with malnutrition are underweight for their height and have low albumin. Patients with a vitamin deficiency do not display these symptoms; symptoms are always dependent upon the vitamin in which the patient is deficient.

What is formed as a result of small blood vessel damage with superficial partial-thickness burn injuries? 1 Pain 2 Eschar 3 Edema 4 Blisters

4 In superficial partial-thickness wounds, the upper third of the dermis is where small blood vessels are injured, which results in leakage of large amounts of plasma into the epidermis. This process leads to the lifting of the heat-destroyed epidermis, causing blisters. In superficial partial-thickness wounds the nerve endings are exposed; this is responsible for the increase in pain at the site of injury. Eschar formation is absent in superficial partial-thickness wounds. The inflammatory reaction in the skin leads to the mild to moderate edema at the site of superficial partial-thickness wounds.

Which type of burn is often referred to as a scald burn? 1 Contact 2 Dry heat 3 Chemical 4 Moist heat

4 Moist heat burns are also referred to as scald burns, which are caused by contact with hot liquids or steam. Contact burns occur when hot metal, tar, or grease contacts the skin, often leading to a full-thickness injury. Dry heat burns are caused by open flame in house fires and explosions. Chemical burns usually occur in the home setting or in an industrial accident. They also can be the result of an assault. Injury occurs when chemicals directly contact the skin or are ingested.

The nurse is providing teaching about pancreatic enzyme replacement to a patient diagnosed with chronic pancreatitis. What statement by the patient indicates need for further teaching? 1 "I will swallow the tablet without chewing." 2 "I won't mix the enzyme with protein foods." 3 "I will take my pancreatic enzymes after my antacid." 4 "I will take the pancreatic enzyme half an hour before meals."

4 Pancreatic enzymes should be taken with meals and snacks, not a half hour before meals. The pill should be swallowed without chewing. The enzyme should not be mixed with protein foods. The pancreatic enzyme should be taken after an antacid.

The nurse assists with the intubation of an 80-kg patient who will receive mechanical ventilation with positive end-expiratory pressure (PEEP) ventilation. When monitoring the patient, the nurse ensures that which settings are maintained? 1 FiO 2 as high as possible 2 Tidal volume of 400 mL 3 Oxygen flow rate of 20 L/min 4 PEEP pressure between 5 and 15 cm H 2O

4 Patients receiving PEEP ventilation should have pressure settings between 5 and 15 cm H2O. Because prolonged use of high FiO 2 can damage lungs, the FiO 2 should be lowered to the lowest possible amount. The oxygen flow rate should be 40 L/min. The patient's tidal volume should be 7 to 10 mL/kg; for this patient, the range would be 560 to 800 mL. (EAQ)

When providing discharge teaching to a patient with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? 1 Nonabsorbable antibiotics 2 Potassium-sparing diuretics 3 Vitamin K-containing products 4 Nonsteroidal anti-inflammatory drugs (NSAIDs)

4 Patients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The patient with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

Which rationale best supports the intravenous (IV) administration of fentanyl to a burn patient? 1 The patient has delayed gastric emptying. 2 The drug will be effective more quickly than if given intramuscularly or subcutaneously. 3 It is less likely to interfere with the patient's breathing and oxygenation. 4 The risk of overdose from rapid absorption of drug from the interstitial space is reduced

4 Providing pain relief following a burn injury is a high priority. The most important reason to administer pain medication intravenously is to prevent an overdose from the accumulation of drug in the interstitial space during the fluid shift of the emergent phase of burn injury. When edema is present, cumulative doses may be rapidly absorbed while the fluid shift is resolving, resulting in lethal blood levels of analgesics. Giving the drug by the IV route instead of intramuscularly, subcutaneously, or via oral routes does increase the rate of effect, but that is not as important as the prevention of overdose. Respiratory rate and breathing must be monitored closely with IV administration of narcotics.

Which is a risk factor for the development of hepatitis C? 1 Consuming shellfish 2 Traveling internationally 3 Chronic alcohol consumption 4 Employment in the health care field

4 Risk factors for hepatitis C include illicit drug use by IV or intranasal route, unsanitary tattoo equipment, and current or former employment in the health care field (because health care workers can easily be exposed to blood and body fluids). Hepatitis A can be contracted by consuming contaminated shellfish. Hepatitis E can be contracted by individuals who travel to countries with poor sanitation. Chronic alcohol consumption is a risk factor for cirrhosis, not hepatitis.

A patient with burns has pulmonary edema. Which drug will likely be administered to the patient? 1 Antacids 2 Diuretics 3 Paralytics 4 Beta blockers

4 The patient with burns has respiratory problems like pulmonary edema due to shock and stress. Patients with pulmonary edema and any degree of heart failure may receive beta blockers to improve left ventricular function and prevent or treat pulmonary edema. Diuretics, a mainstay of therapy for pulmonary edema from other causes, may or may not be used in the resuscitation phase. Paralytic drugs may need to be given if a patient needs to be mechanically ventilated. Antacids are not a priority for burn resuscitation.

Which statement is true regarding the layers of skin? 1 The dermis is thinner than the epidermis. 2 The epidermal layer nourishes the dermal layer of the skin. 3 The epidermis and subcutaneous tissue are separated by the basement membrane. 4 The dermis consists of appendages such as sweat glands and oil glands

4 The skin is the largest organ of the body, and it has two major layers, the epidermis and the dermis. The sweat glands, oil glands, and hair follicles are dermal appendages. The dermis is thicker than the epidermis and is made up of collagen, fibrous connective tissue, and elastin fibers. The epidermis has no blood vessels; therefore, nutrients must diffuse from the dermis. The subcutaneous tissue lies below the dermis and is separated from the dermis by the basement membrane.

Which physiologic outcome describes the goal of topical sulfadiazine in the care of a patient with a burn injury? 1 Enhanced cell growth 2 Reduced need for a skin graft 3 Prevention of cross-contamination from other patients in the unit 4 Reduction of bacterial growth in the wound and prevention of sepsis

4 Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds. Topical antimicrobials such as sulfadiazine do not prevent cross-contamination from other patients in the unit. They do not enhance cell growth, nor do they minimize the need for a skin graft.

The registered nurse is teaching the student nurse about the functions of the skin. What statement made by the student nurse indicates a need for further teaching? 1 "Skin activates vitamin A when exposed to sunlight." 2 "Skin triggers a response if there is any sensation of pain." 3 "Skin helps in the maintenance of fluid and electrolyte balance." 4 "Skin acts as a protective barrier against injury and microbial invasion."

4 When the skin is exposed to sunlight, Vitamin D is activated. When there is a sensation of pain, the skin triggers a response, which allows a person to react. Skin helps maintain fluid and electrolyte balance through evaporation. Skin acts as a protective barrier against injury and microbial invasions.

normal ALT levels what would high levels indicate?

4-36 u/L high levels indicate liver damage

normal value for glucose what could high levels indicate?

82-110 mg/dL high levels could indicate acute pancreatitis

Which action will the nurse take first for a client being mechanically ventilated who begins to pick at the bedcovers? A. Assess for adequate oxygenation B. Administering the prescribed sedating drug C. Explaining to the client that the tube helps with breathing D. Requesting that the family leave to decrease the client's agitation

A restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia

Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)? A.24-year-old male admitted with blunt chest trauma and aspiration B.56-year-old male with a history of alcohol abuse and chronic pancreatitis C.72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells D.82-year-old female on antibiotics for pneumonia

A (ppt slide)

A patient with acute pancreatitis is being discharged to home. What patient teaching will the nurse provide regarding when the patient should notify the health care provider? SATA A. If acute abdominal pain occurs B. jaundice C. clay colored stools D. dark urine

A, B, C, D The patient should be instructed to notify the health care provider if acute abdominal pain occurs. Also, jaundice, clay-colored stools, or dark urine should be reported, because these are signs of biliary tract disease that may indicate complications as the disease progresses.

The nurse will include what postop teaching when caring for the client who is preparing to undergo endoscopic cholecystectomy? SATA A. "You'll have a small, midline abdominal incision" B. " You can't eat or drink for a few days after the procedure" C. "You won't be able to return to regular activity for several weeks" D. "Generally the pain associated with this procedure is minimal" E. "This procedure has a low incidence of infection" F. "The hospital stay after this procedure is typically 3-4 days"

A, D, E (Iggy 1197)

Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe bun injury? (SATA) A. Place client in isolation B. Encourage multiple visitors to support client C. Ensure that no plants or flowers are in the client's room D. Teach family members not to bring fresh fruit and vegetables to the client E. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another

A,C,D (Iggy 502)

When a patient with acute pancreatitis is asked about pain, he says that it is intense and continuous. He states that sometimes when he curls up in a fetal position the pain eases. Which medication does the nurse recognize that will provide the most comprehensive pain relief at this time? A. PCA morphine sulfate B. IM fentanyl (Sublimaze) C. PCA meperidine (Demerol) D. Oral hydromorphone (Dilaudid)

ANS: A Meperidine is not a good choice because it can cause seizures, especially in older adults. While hydromorphone is a good choice with acute pancreatitis pain, IV is the best route. Fentanyl is a good alternative, but the route chosen should be IV or transdermal. Another option is epidural analgesia.

Mr. Sully has just returned from an endoscopic retrograde choleangiopancreatography (ERCP). Upon returning to the floor which action should the nurse take first? A. obtain a set of vital signs B. assess for gag reflex C. assess LOC D. administer pain medication

A. always first assessment of ABC, gag reflex is important before eating

Which lab finding supports the medical diagnosis of cirrhosis? A. platelets 120,000u/L B. amylase 1200 u/L C. Lipase 800u/L D. WBC 14,000 u/L E. glucose 120 mg/dL

A. normal platelet count is 150,000-450,000 u/L, so 120,000 is low. platelets are made in the liver so this finding would indicate liver damage.

The patient with acute pancreatitis has been NPO but is now tolerating food. What education will the nurse provide regarding nutrition? A. Small and frequent meals are best. B. Use of alcohol and caffeine should be consumed in moderation. C. Expect to experience nausea and vomiting as you begin to consume foods. D. Low-carbohydrate, high-protein, and high-fat foods should be consumed.

ANS: A Patients may experience nausea and vomiting but should not expect this to happen. High-carbohydrate, high-protein, and low-fat foods should be included in the diet. Alcohol and caffeine should be avoided.

A 68-year-old patient presents to the ED the day after Thanksgiving, stating that he has "eaten and drunk quite a bit." He states that about 1 hour ago he experienced a sudden onset of pain in the left upper quadrant that radiates to his left flank. He rates the pain as an 8 on a 0-to-10 scale. The patient is admitted with acute pancreatitis. Which laboratory finding corroborates the diagnosis of acute pancreatitis? A. Serum lipase, 150 U/L B. Serum amylase, 200 U/L C. Serum glucose, 80 mg/dL D. White blood cells (WBCs), 6000 mcL

ANS: B A serum amylase of 200 U/L is elevated (normal range is approximately 23 to 85 U/L). Amylase, lipase, WBC, and glucose are often higher than normal in patients with acute pancreatitis.

What is the priority nursing intervention in the management of a patient with decompensated cirrhosis? A. Limiting protein intake B. Managing nausea and vomiting C. Monitoring fluid intake and output D. Elevating the head of bed >30 degrees

ANS: B Decompensated cirrhosis has multiple complications. However, bleeding esophageal varices can present a life-threatening emergency. Preventing nausea and vomiting is an important intervention in the management of esophageal varices. Monitoring protein, fluid balance, and patient positioning are also important interventions in the care of the patient with end-stage liver disease.

A patient with chronic cholecystitis reports pruritus, clay-colored stools, and voiding dark, frothy urine. Which laboratory analysis is a priority in the nurse's assessment of this patient? A. Lipase level B. Total bilirubin C. Liver function tests D. White blood cell count

ANS: B Excess circulating bilirubin present with chronic cholecystitis is responsible for pruritus and changes in stool and urine color. Cholecystitis is associated with several risks including hepatic disease, pancreatitis, and peritonitis. Monitoring liver function, pancreatic laboratory values, and white blood cell counts is also very important.

The patient's assessment reveals yellowish coloration of skin and sclerae. Which laboratory values does the nurse anticipate? A. Increased urine bilirubin, decreased direct bilirubin B. Increased direct bilirubin, increased indirect bilirubin C. Decreased direct bilirubin, increased indirect bilirubin D. Increased direct bilirubin, decreased indirect bilirubin

ANS: B When a patient's skin is jaundiced, laboratory values of indirect and direct bilirubin are increased. Urine bilirubin is also increased. Urobilinogen in stool is normal to decreased, but in urine it is normal to increased.

In preparing to care for a patient with acute pancreatitis, which conditions does the nurse recognize as potential complications of acute pancreatitis? (Select all that apply.) A. Strep throat B. Pleural effusion C. Diabetes mellitus D. Pancreatic infection E. Acute kidney failure

ANS: B, C, D, E All, with the exception of strep throat, are potential complications of acute pancreatitis.

A 59-year-old patient with a history of alcohol abuse spanning 15 years has been diagnosed with cirrhosis. The patient will be undergoing abdominal paracentesis today. When a complete assessment of this patient is performed, what other signs and symptoms does the nurse expect? (Select all that apply.) A. Muscle twitching B. Dry skin with rash C. Personality changes D. Peripheral dependent edema E. Ecchymosis, spider angiomas

ANS: B, D, E Personality changes and muscle twitching are findings that may be seen when the patient with cirrhosis develops portal-systemic encephalopathy. Additional manifestations that may be found on assessment include palmar erythema, clubbing of fingernails, and fixed flexion of fingers.

Which assessment finding requires immediate nursing intervention in a patient with severe ascites? A. Confusion B. Temperature 38.2º C C. Tachycardia, rate 110 beats/min D. Shallow respirations, rate 32 breaths/min

ANS: D Ascites can increase abdominal distention, which interferes with lung expansion and compromises ventilation and oxygenation. Risk for infection, fluid displacement, and confusion are also assessment variables requiring monitoring in a patient with ascites.

Which patient is more likely to develop gallstones? A. 45 year old Caucasian female with a family history of gallstones B. 55 year old African-American male with a history of diabetes mellitus C. 62 year old Hispanic/Latino female with a history of irritable bowel syndrome D. 60 year old obese, American-Indian female with a history of diabetes mellitus

ANS: D Risk factors for developing gallstones include female gender, obesity, family history of gallstones, diabetes mellitus, American-Indian and Caucasian descent, rapid change in weight, and advanced age. More risk factors increase the likelihood of developing gallstones.

In the care of a patient with acute pancreatitis, which assessment parameter requires immediate nursing intervention? A. Heart rate of 105 beats/min B. Serum glucose of 136 mg/dL C. Blood pressure of 102/76 mm Hg D. Respiratory rate of 28 breaths/min

ANS: D The patient with pancreatitis may develop pulmonary complications, pleural effusions, pulmonary infiltrates, and acute respiratory failure or ARDS. Increases in respiratory effort is an important assessment variable in the care of a patient with pancreatitis. Patients may also be hyperglycemic and hypovolemic. Assessing and treating endocrine function of the pancreas and perfusion variables are also important.

The nurse is caring for a client who has had paracentesis performed. Which nursing intervention is appropriate? SATA A. Keep head of bed flat B. Measure, describe, and record drainage C. Ambulate 30 minutes post procedure D. Weigh client E. label fluid container and send for laboratory analysis

B, D, E

The nurse is encouraging range-of-motion exercises for the client, who states, "This hurts terribly; I don't want to do this." Identify the appropriate nursing response(s). SATA A. You have to do the exercises to get well B. Range of motion helps promote mobility C. Just visualize a beach to get your mind off of the pain D. Let me check when you were last given pain medication E. Which techniques for pain management have you used in the past that was helpful? F. The health care provider has ordered these exercises, and it is important that you do them as instructed.

B, D, E (Iggy 503)

The community nurse is talking with four clients who have reported digestive concerns. Which client does the nurse recognize as most likely to experience gallstone production? SATA A. 23 year old Caucasian vegetarian who is a dancer B. 35 year old American Indian who works in construction C. 48 year old Canadian who manages a fast-food restaurant D. 59 year old Asian American who is an investment banker E. 64 year old Mexican American who resides with grandchildren

B, E (Iggy 1193)

Which of the following delegated tasks for a client at risk for hep B requires further teaching for the new RN? A. asking the CNA to obtain vital signs B. asking the LPN to teach about the vaccine side effects C. asking the CNA to document intake and output D. asking the LPN to administer a promethazine suppository

B. RN's have to do all initial teaching

The nurse is caring for a client who is jaundiced and reports pruritus. Which intervention will the nurse include in the plan of care? A. monitor the client's vital signs and intake and output B. instruct the client to scratch with knuckles instead of nails C. Assist the client with a hot bath and apply moisturizer D. Encourage the client to eat a high-protein, high-cholesterol diet

B. pruritus is itchy skin caused by liver damage, scratch with knuckles to avoid skin damage which is a risk for infection

What type of acid/base problem with the nurse expect in a client who is being insufficiently mechanically ventilated for the past 4 hours and whose most recent arterial blood gas results include a pH of 7.29? A. metabolic acidosis with an acid excess B. metabolic acidosis with a base deficit C. respiratory acidosis with an acid excess D. respiratory acidosis with a base deficit

C When a person being mechanically ventilated is insufficiently ventilated respiratory acidosis occurs with retention of carbon dioxide. The retained carbon dioxide is converted to hydrogen ions resulting in an acid excess

Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left sided tension pneumothorax? A. the client has bloody sputum and wheezes B. left chest caves in on inspiration and "puffs out" on expiration C. chest is asymmetrical and trachea deviates toward the right side D. the left lung field is dull to percussion and crackles are present on auscultation

C symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis and hyperresonance to percussion over the affected area

Which of the following is the most important for the nurse to include related to tertiary prevention for a client with Laenac's cirrhosis? A. administer the hep B vaccine B. teach client to avoid fried foods C. teach client to reduce sodium intake D. teach client to drink bottled water when traveling

C tertiary prevention includes preventing complications, eating a low sodium diet helps prevent ascites

You are preparing to teach primary prevention for cholecystitis to a group of young mothers. you plan to include all of the following except: A. broiled and grilled food is less likely to cause gallstones B. birth control with estrogen can increase your risk for cholecystitis C. it is important to wash your hands for 20 seconds after using the restroom D. it is important to maintain a healthy weight

C washing hands does not help prevent cholecystitis, it can however help prevent hepatitis A

What is the primary emphasis for the nurse who is providing care to a client with acute respiratory distress syndrome currently in the exudative management stage of the disorder? A. Assessing for abnormal lung sounds B. Performing meticulous mouth assessments during mechanical ventilation C. Assessing the client at least hourly for tachypnea and dyspnea D. Monitoring urine output to identify multiple organ dysfunction syndrome early

C the exudative phase includes early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid filled.

The nurse is caring for four clients. Which client is at the highest risk for hepatitis B infection? A. 24 year old with abdominal pain who just returned from central America B. 40 year old who is 2 days postpartum and is breastfeeding C. 65 year old who reports using street drugs 10 years ago when homeless D. 81 year old who donated own blood before a surgical procedure

C (Iggy 1181)

Which teaching will the nurse provide when discharging a client with chronic pancreatitis? A. Weight reduction and daily exercise regimen B. Constipation precautions including daily laxative use C. Dietary adjustments to include avoiding high-fat food, caffeine, and alcohol D. relaxation techniques and stress management

C (Iggy 1204)

The nurse is trouble-shooting multiple ventilator alarms sounding for a client who is intubated and being mechanically ventilate. The alarms persist despite suctioning, repositioning the client, and ensuring that the ventilator tubing is unobstructed. Which actions will the nurse perform next? SATA A. Turn off all ventilator alarms until a cause is found to prevent scaring the client B. page the primary health care provider to request additional sedation C. ensure that the endotracheal tube marking is at the client's incisor D. Increase the PEEP to improve gas exchange E. Disconnect the client from the ventilator and use the manual resuscitation bag F. change all ventilator tubing G. Stat page the respiratory therapist H determine when the client received the last dose of the paralytic agent

C, E, G (Iggy 633)

You are the nurse on a medical unit. Which client would you see first? A. Mr. Smith who was admitted for pancreatitis with a pin level of 8 B. Mrs. Fisher a client with cholecystitis who is complaining of nausea C. Mr. Rodriguez admitted with cirrhosis with a blood pressure of 85/63 D. Mr. Green admitted with hepatitis with a temp of 100 degrees

C. due to risk for hemorrhage related to circulation

medical term for the presence of gallstones

Cholelithiasis

What type of percussion note or sound will the nurse expect on the affected chest side of a client who has a hemothorax? A. hypertympanic B. hyperresonant C. crackling D. dull

D

Which client will the nurse consider to be at the greatest risk for developing acute respiratory distress syndrome (ARDS)? A. A 22 year old with a fractured clavicle B. A 39 year old with uncontrolled diabetes C. A 56 year old with chronic kidney disease D. A 74 year old who aspirates a tube feeding

D

The nurse closely monitors the client with acute pancreatitis for which life-threatening complication? A. jaundice B. type I diabetes mellitus C. Abdominal pain D. DIC

D (Iggy 1199)

Which type of grafting method is preferred in regards to reducing the risk of infection? 1 Allograft 2 Autograft 3 Xenograft 4 Cultured skin

Grafting is used for wound closure when full-thickness injuries and deep partial-thickness injuries occur because of absence of wound contraction. Autografting is the procedure of taking a patient's own healthy skin with intact tissue integrity and transplanting it to the site of a burn injury. This process reduces the risk of infections.

Inflammation of the gallbladder, a small, digestive organ beneath the liver

cholecystitis

secretes glucagon to increase glucose levels and secretes somatostatin to exert a hypoglycemic effect; islets of langerhorn secrete insulin

endocrine pancreas

secretes sodium bicarbonate to neutralize acidity of stomach, and excretes enzymes for digestion of carbs, fats and proteins

exocrine pancreas

stores and concentrates bile and contracts to force bile into duodenum during digestion of fats

gallbladder