Exam 1 Med Surg

A patient is determined to be at risk for the development of Clostridium difficile-associated diarrhea. What medication should the nurse be aware may cause this infection? Fentanyl Lorazepam Cisatracurium Esomeprazole

D

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?

27%

A patient's vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac output is 4.7 L/min. The patient's stroke volume is _____ mL. (Round to the nearest whole number.)

52

The nurse is monitoring a patient in ICU. Which ScvO 2/SvO 2 reading should the nurse report to the primary health care provider? 68% 54% 72% 78%

54%

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?

600 mL

A feeding tube is placed in a patient receiving positive pressure ventilation to prevent inadequate nutrition. What should the nurse avoid while verifying the placement of the feeding tube? Listening for air after injection X-ray confirmation before initial use Review of routine x-rays and aspirate Marking and assessing the tube's exit site

A

A nurse is caring for a patient undergoing mechanical ventilation who is also receiving positive end-expiratory pressure (PEEP). What is the outcome that the nurse hopes to achieve with PEEP? Expand collapsed alveoli Decrease alveolar volume Decrease bronchospasms Prevent spontaneous breathing

A

A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next? a. Verbally coach the patient to breathe with the ventilator. b. Sedate the patient with the ordered PRN lorazepam (Ativan). c. Manually ventilate the patient with a bag-valve-mask device. d. Increase the rate for the ordered propofol (Diprivan) infusion.

A

A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the SBT? a. New ST segment elevation is noted on the cardiac monitor. b. Enteral feedings are being given through an orogastric tube. c. Scattered rhonchi are heard when auscultating breath sounds. d. hydromorphone (Dilaudid) is being used to treat postoperative pain.

A

A patient with a burn inhalation injury is receiving albuterol for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? Tachycardia Hypokalemia Restlessness Gastrointestinal (GI) distress

A

A patient with a heart rate of 68 beats/minute has a stroke volume (SV) of 100 mL/beat. What is this patient's cardiac output (CO)? 6.8 L/min 2.4 L/min 9.2 L/min 10.3 L/min

A

A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial pressure is 90/46. b. The stroke volume is increased. c. The heart rate is 58 beats/minute. d. The stroke volume variation is 12%.

A

According to the Rule of Nines for calculating the percentage of burns, the nurse should assign what percentage to a burn in the genitalia? 1% 4.5% 9% 18%

A

An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first? a. Remove nonadherent clothing and wristwatch. b. Apply an alkaline solution to the affected area. c. Place a cool compress on the area of exposure. d. Cover the affected area with dry, sterile dressings.

A

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider when a nondiabetic patient's serum glucose is elevated.

A

The nurse calculates the cardiac output of a patient whose stroke volume is 60 mL and heart rate is 70 beats/minute, using the formula cardiac output (CO) = stroke volume X heart rate. What is the patient's cardiac output? 4.2 L 6.8 L 14.5 L 22.16 L

A

The nurse educator is teaching a group of nursing students about critical care nursing. Which statement by a student indicates appropriate understanding of this nursing specialty? "Critical care nursing is a specialty dealing with human responses to life-threatening problems." "Critical care nursing is a specialty dealing with the care of adult patients in a variety of settings." "Critical care nursing is a specialty dealing with people of all ages with mental illness or mental distress." "Critical care nursing is a specialty dealing with the care of women throughout their pregnancy and childbirth."

A

The nurse is concerned about a patient's stroke volume. What determining factors should the nurse consider when determining stroke volume? Preload, afterload, and contractility Cardiac output, heart rate, and body surface area Afterload, cardiac output, and mean arterial pressure Cardiac index, mean arterial pressure, and blood pressure

A

The nurse is positioning a patient with severe acute respiratory distress syndrome (ARDS). In what position should the nurse place the patient to improve oxygenation? A. Prone B. Lateral C. Supine D. Lateral recumbent

A

The nurse is providing care to a patient who is admitted to the intensive care unit (ICU) and is malnourished. Based on these data, with which discipline will the nurse collaborate to plan care for this patient? Dietitian Physical therapist Occupational therapist Clinical nurse specialist

A

The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? Intravenous (IV) morphine sulfate Subcutaneous (SQ) tetanus toxoid Intramuscular (IM) hydromorphone Oral (PO) oxycodone and acetaminophen

A

When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse plan to do? a. Discontinue the catheter and culture the tip. b. Use the catheter only for fluid administration. c. Change the flush system and monitor the site. d. Check the site more frequently for any swelling.

A

Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take action? a. The right hand feels cooler than the left hand. b. The mean arterial pressure (MAP) is 77 mm Hg. c. The system is delivering 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 2 days previously.

A

Which complication is caused by an electric burn? Myoglobinuria Systemic toxicity Protein hydrolysis Metabolic asphyxiation

A

Which is an alteration in mentation that can occur in a patient in the intensive care unit (ICU)? Delirium Lethargy Restlessness Nighttime agitation

A

patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

A

A patient has increased preload. What should the nurse expect administer to this patient to decrease preload? Select all that apply. Select all that apply Diuretic Vasodilator Pain medication Cardiac glycoside Intravenous fluids

A B

patient is brought to the emergency department (ED) with partial-thickness burns on the hands and chest caused by a fire at the patient's house. What actions should the nurse perform to provide appropriate burn management for this patient? Select all that apply. Select all that apply Assess for inhalation injury. Provide 100% humidified oxygen. Avoid dry dressings on the wounds. Assess airway, breathing, and circulation. Avoid mechanical ventilation for 24 hours.

A B D

A patient is admitted to the ICU. What care should a nurse take to ensure that the patient's sleep cycle is as normal as possible? A. Limit noise in the ICU. B. Schedule regular rest periods. C. Give regular sponge baths to the patient. D. Encourage the caregiver to be with the patient at all times. E. Dim the lights at night and open up the curtains during the day.

A B E

A nurse is attending to a patient with extensive burns. What prophylactic treatment should the nurse plan to prevent a Curling's ulcer in this patient? Select all that apply. Select all that apply Antacids Antidiarrheal H 2-histamine blockers Proton pump inhibitors Calcium channel blockers

A C D

A nurse is providing care to a patient admitted to the burn unit. Which pathophysiologic changes does the nurse anticipate in this patient? Select all that apply. Select all that apply Increased viscosity Decreased hematocrit Decreased blood volume Increased vascular permeability Decreased peripheral resistance

A C D

When planning for burn management, which patients should the nurse refer to a burn center? Select all that apply. Select all that apply Patients with hydrochloric acid burns Patients of all ages with first-degree burns Patients of all ages with third-degree burns Patients with 25% deep partial-thickness burns Patients with 5% superficial partial-thickness burns

A C D

A patient with severe inhalation burns has been receiving treatment for 24 hours. When assessing the patient, what findings would indicate respiratory distress? Select all that apply. Select all that apply Restlessness Increased sleep Increased agitation Increased water intake Increased rate of breathing

A C E

Which complications occur in a patient with metabolic asphyxiation? Select all that apply. Select all that apply Hypoxia Cardiac standstill Protein hydrolysis Hydrogen cyanide poisoning Acute respiratory distress syndrome

A D

When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply. Select all that apply Increasing hoarseness Location of contact points Leathery white charred skin Darkened oral or nasal membranes Productive cough with black sputum

A D E

A patient is scheduled to have an insertion of a pulmonary artery catheter for hemodynamic monitoring. What conditions should the nurse recognize are contraindicated for insertion of the catheter? Select all that apply. Select all that apply Coagulopathy Cardiogenic shock Fulminant myocarditis Endocardial pacemaker Mechanical tricuspid valve

A d e

The nurse is caring for a patient in the intensive care unit. When monitoring the patient, conditions may result in a hypermetabolic state? Select all that apply. Select all that apply Burns Sepsis Acute liver disease Acute kidney injury Chronic heart disease

A B

A patient is admitted to the ICU. What care should a nurse take to ensure that the patient's sleep cycle is as normal as possible? Select all that apply. Select all that apply Limit noise in the ICU. Schedule regular rest periods. Give regular sponge baths to the patient. Encourage the caregiver to be with the patient at all times. Dim the lights at night and open up the curtains during the day.

A B E

A patient who escaped from a burning building, which was enclosed with no ventilation, is brought to the emergency department. The patient is confused, has difficulty breathing, and has nasal burns. Which condition does the nurse suspect? Pulmonary edema Lower airway injury Upper airway injury Carbon monoxide poisoning

B

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

B

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral feedings. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day.

B

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

B

A patient receiving intraaortic balloon pump (IABP) therapy is having the catheter removed. What should the nurse ensure occurs during the procedure? The pump is turned off The pump remains turned on The patient is placed in a side-lying position The intravenous fluids are reduced to keep vein open status

B

A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care? a. Administer prescribed sedatives or opioids at bedtime to promote sleep. b. Cluster nursing activities so that the patient has uninterrupted rest periods. c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. d. Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep.

B

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.

B

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess pain level. c. Check potassium level. b. Place on heart monitor. d. Assess oral temperature.

B

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 219 mL/hr b. 938 mL/hr c. 625 mL/hr d. 1875 mL/hr

B

A patient with severe left ventricular failure is considering artificial heart transplantation. What should the nurse inform the patient is a long-term treatment associated with this device? Beta-blockers Anticoagulation Antibiotic therapy Immunosuppressive agents

B

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "Why do you feel that way? It will get better as your recovery progresses." d. "It is really too early to know how much your life will be changed by the burn."

B

After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take? a. Administer IV diuretic medications. b. Increase the IV fluid infusion per protocol. c. Increase the infusion rate of IV vasodilators. d. Elevate the head of the patient's bed to 45 degrees.

B

An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to a. give PRN lorazepam (Ativan) and cancel the transfer. b. inform the receiving nurse and then transfer the patient. c. notify the health care provider and postpone the transfer. d. obtain an order for restraints as needed and transfer the patient.

B

An older adult patient reports having used an "iron lung" after contracting polio as a child. The nurse knows this patient is referring to which type of mechanical ventilation? Positive pressure Negative pressure Volume ventilation Pressure ventilation

B

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours. c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108.

B

The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient's a. lipase level. c. urinary output. b. temperature. d. body mass index.

B

The intensive care unit (ICU) nurse educator determines that teaching a new staff nurse about arterial pressure monitoring has been effective when the nurse a. balances and calibrates the monitoring equipment every 2 hours. b. positions the zero-reference stopcock line level with the phlebostatic axis. c. ensures that the patient is supine with the head of the bed flat for all readings. d. rechecks the location of the phlebostatic axis with changes in the patient's position.

B

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function? a. Monitor white blood cells (WBCs). b. Continue to measure the urine output. c. Assess that blisters and edema have subsided. d. Encourage the patient to eat an adequate number of calories.

B

The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe? a. The RN plans to suction the patient every 1 to 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes the connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 48 hours.

B

The nurse is assessing a patient placed on mechanical ventilation and hears breath sounds on the right but not on the left side of the chest. What common complication should the nurse immediately notify the health care provider about? Hypertension Pneumothorax Electrolyte imbalance Increased cardiac output

B

The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider? a. The patient has a positive Allen test result. b. There is redness at the catheter insertion site. c. The mean arterial pressure (MAP) is 86 mm Hg. d. The dicrotic notch is visible in the arterial waveform.

B

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? a. Avoid the use of anticoagulant medications. b. Measure the patient's urinary output every hour. c. Provide passive range of motion for all extremities. d. Position the patient supine with head flat at all times.

B

The nurse is providing education to a patient who is in the rehabilitation phase of burn recovery after burning the arm with scalding water. Which of these statements by the patient indicates a need for further instruction? "If the area itches, I can apply a water-based moisturizer." "After a month, I will be able to go to the beach to get a tan." "I will need to wear the pressure garment for 24 hours a day." "I will continue the range-of-motion exercises on a regular schedule."

B

The nurse working in the intensive care unit (ICU) is taking care of a patient on a mechanical ventilator who had a motor vehicle accident two weeks ago. What does the nurse know about this situation? A. The patient has severe hypoxia due to acute respiratory failure. B. The ventilator will support the patient until he or she can breathe on his or her own. C. The patient suffered from a chronic pulmonary disease before the accident. D. The patient will be on long-term ventilation until the family decides to withdraw ventilator support.

B

The patient in the acute phase of burn care has electrical burns on the left side of the body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient? A. Maintain a neutral pH B. Maintain fluid balance C. Replace the blood lost D. Replace serum potassium

B

To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. obtain a portable chest x-ray. b. use an end-tidal CO2 monitor. c. auscultate for bilateral breath sounds. d. observe for symmetrical chest movement.

B

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

B

When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most pertinent measurement for the nurse to obtain is a. central venous pressure (CVP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP).

B

Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

B

Which patient should the nurse assess first? a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who is scheduled for a dressing change d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr

B

Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures? Sunburn Full thickness burn Deep partial thickness burn Superficial partial thickness burn

B

While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best? a. Tell the family members that watching the resuscitation will be very stressful. b. Ask family members if they wish to remain in the room during the resuscitation. c. Take the family members quickly out of the patient room and remain with them. d. Assign a staff member to wait with family members just outside the patient room.

B

While evaluating a mechanically ventilated patient, the nurse notes that the auto-PEEP has been activated. Which mode of mechanical ventilation does the nurse suspect? Volume mode Pressure mode Continuous positive airway pressure Positive end-expiratory pressure mode

B

While the patient's full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination? a. Use sterile gloves when removing dressings. b. Wear gown, cap, mask, and gloves during care. c. Keep the room temperature at 70° F (20° C) at all times. d. Give IV antibiotics to prevent bacterial colonization of wounds.

B

A patient is receiving continuous arterial BP monitoring. What actions should the nurse take to avoid thrombus formation and maintain line patency? Select all that apply. A. Ensure the insertion site is flexible. B. Ensure that the flush bag contains fluid. C. Change pressure tubing every five hours. D. Ensure that the flush system is delivering 3 to 6 mL/hr. E. Ensure that the pressure bag of the flush system is inflated to 300 mm Hg.

B D E

A patient with partial-thickness burns is now allowed oral feedings. What nursing interventions should the nurse perform to maintain the patient's nutrition? Select all that apply. Suggest low-calorie food. Suggest a high-protein diet. Suggest reduced fluid intake. Suggest a high-carbohydrate diet. Ask caregivers to get the patient's favorite food.

B D E

When performing a dynamic response test, the nurse observes the following tracing. What action should the nurse perform based on this tracing? A. Flush the line B. Reconfirm zeroing C. No action required D. Reposition the wrist

C

The nurse reviews medical records of several patients and concludes that which patients are appropriate candidates for parenteral nutrition? Select all that apply. Select all that apply Some correct answers were not selected A patient with arthritis A patient with pancreatitis A patient with paralytic ileus A patient with hypothyroidism A patient with severe diarrhea

B C E

A nurse is transferring to work as a critical care nurse. Which skill is essential for the nurse to have in order to be effective at being a critical care nurse? Planning Evaluation Assessment Collaboration

D

. The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted? a. Heart rate is slow at 58 beats/min. b. Mean arterial pressure (MAP) is 56 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.

C

A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? a. The patient's heart rate is 97 beats/min. b. The patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 450 mL.

C

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature c. Extremity movement b. Peripheral pulses d. Pupil reaction to light

C

A patient has sustained thermal injuries amounting to approximately 30% of his or her total body surface area. What action should the nurse take first? Cover the burned body area with ice. Immerse the burned body area in cool water. Check for a patent airway, breathing, and circulation. Cover the burned area with a clean, cool, tap water-dampened towel.

C

A patient is experiencing symptoms of anxiety during hospitalization in the intensive care unit. The nurse anticipates that which medication will be administered? Propofol Fentanyl Lorazepam Esomeprazole

C

A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin does the nurse inspect for damage? Epidermis only Muscle and bone Epidermis and dermis Epidermis, dermis, and subcutaneous tissue

C

A patient sustains burns covering 35% of the body surface area. The patient weighs 100 kg. Which action is mostappropriate for the nurse to take during the early course of the patient's care? Administering 3500 mL of colloid IV fluids over the 8 hours after injury Administering 140 mL/hr of colloid IV fluids for the 24 hours after injury Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury Administering 14,000 mL of crystalloid IV fluids over the 12 hours after injury

C

A patient with an implanted ventricular assist device (VAD) is being prepared for discharge. To ensure the patient's safety, what should the nurse make sure is completed prior to the patient leaving the hospital? Home care referral Diet and activity teaching Battery charger in the home Oxygen condenser delivered

C

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas c. Vanilla milkshake b. Orange gelatin d. Whole grain bagel

C

A patient's blood pressure is 172/94 mm Hg. What would the nurse calculate as being this patient's mean arterial pressure (MAP)? 80 100 120 160

C

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "Do you think dark beige makeup will cover this scar?" d. "I don't think my boyfriend will want to look at me now."

C

After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring c. Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours d. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP)

C

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met? a. Urine output of 25 mL/hr b. Heart rate of 110 beats/minute c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat

C

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours. b. Continuing to monitor the laboratory results. c. Increasing the rate of the ordered IV solution. d. Typing and crossmatching for a blood transfusion.

C

The nurse is caring for a patient being mechanically ventilated. Which intervention limits the occurrence of auto-positive end-expiratory pressure (PEEP) during mechanical ventilation? A. Using bronchoconstrictors B. Increasing the inspiratory times C. Decreasing the respiratory rates D. Using small-diameter endotracheal tubes

C

The nurse is caring for a patient with a tracheostomy on mechanical ventilation when the alarm displays low tidal volume and low-pressure limit. What does the nurse infer from this finding? Total extubation Insufficient gas flow Tracheotomy cuff leak Change in patient's respiratory rate

C

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit of 53% c. Serum potassium of 6.1 mEq/L b. Serum sodium of 147 mEq/L d. Blood urea nitrogen of 37 mg/dL

C

The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark, and the patient is anxious and restless. Which action should the nurse take next? a. Check the O2 saturation. b. Offer reassurance to the patient. c. Listen to the patient's breath sounds. d. Notify the patient's health care provider.

C

The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding? a. Reposition the patient every 1 to 2 hours. b. Increase suctioning frequency to every hour. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the ET before suctioning.

C

When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

C

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? Increased inflation of the lungs Prevention of barotrauma to the lung tissue Prevention of alveolar collapse during expiration Increased fraction of inspired oxygen concentration (FIO 2) administration

C

Which action should the nurse take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery? a. Fast flush the arterial line. b. Check the left hand for pallor. c. Assess for cardiac dysrhythmias. d. Re-zero the monitoring equipment.

C

Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patient was last suctioned 6 hours ago. b. The patient's oxygen saturation drops to 93%. c. The patient's respiratory rate is 32 breaths/min. d. The patient has occasional audible expiratory wheezes.

C

Which burn injury results in tissue anoxia? Thermal burn Chemical burn Electrical injury Smoke and inhalational injury

C

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Inspect the contact burns. c. Stabilize the cervical spine. b. Check the blood pressure. d. Assess alertness and orientation.

C

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A patient who has twice-daily burn debridements to partial-thickness facial burns b. A patient who has just returned from having a cultured epithelial autograft to the chest c. A patient who has a weight loss of 15% from admission and will have enteral feedings started d. A patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

C

he family members of a patient who has been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first? a. Explain ICU visitation policies and encourage family visits. b. Escort the family from the waiting room to the patient's bedside. c. Describe the patient's injuries and the care that is being provided. d. Invite the family to participate in an interprofessional care conference.

C

A nurse measures a patient's central venous pressure and recognizes a series of increased readings. What do these increased readings indicate to the nurse? Cardiogenic shock Circulatory failure Left ventricular failure Right ventricular failure

D

A nurse notes decreased reflexes during the physical assessment of a patient who was admitted with a burn injury. What is the likely cause for this clinical manifestation? Decreased water levels Increased sodium levels Increased albumin levels Decreased potassium levels

D

A patient is admitted to the burn center with burns of the face, upper chest, and hands after fireworks exploded in the patient's garage, catching the patient's shirt on fire. On assessment, the nurse notes that the patient is coughing up black sputum, has singed nasal hair, darkened oral and nasal membranes, and smoky breath with increasing shortness of breath and hoarseness. Which of these actions would be the most appropriate for the nurse to take next? Insert a Foley catheter and monitor output. Obtain vital signs and a stat arterial blood gas (ABG). Obtain a sputum specimen and send it to the lab stat. Anticipate the need for endotracheal intubation and notify the health care provider.

D

A burn patient has not received any active tetanus immunization within the previous 12 years. What is the primary nursing measure to help prevent the development of tetanus in the patient? Administer tetanus toxoid Provide musculoskeletal relaxants Provide 100% oxygen to the patient Administer tetanus immunoglobulin

D

A nurse is assessing a patient with a burn injury. Which clinical manifestation does the nurse anticipate due to thrombosis in the capillaries of the burned tissue? Elevated heart rate Elevated hematocrit Decreased blood pressure Decreased erythrocyte count

D

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One-half of the total 24-hour fluid requirement should be administered in the first 8 hours. One-third of the total 24-hour fluid requirement should be administered in the first 4 hours. One-half of the total 24-hour fluid requirement should be administered in the first 4 hours.

D

A nurse is providing care to a patient with a partial-thickness burn. Which clinical manifestation does the nurse anticipate? Coagulation necrosis Damage to all skin elements Destruction of all nerve endings Damage to epidermis and dermis involving varying depths

D

A patient is receiving mechanical ventilation after having a stroke. The nurse determines that the ventilator settings are based on which patient status? Ideal body weight, vital signs, and family preference Ethics committee results, current physiologic state, and ideal body weight Respiratory muscle strength, ethics committee results, and family preference Arterial blood gases (ABGs), current physiologic state, and respiratory muscle strength

D

A patient on positive pressure ventilation has increased sodium retention in the body. A decrease in production of which biologic factor may have caused sodium retention in the patient? Renin Angiotensin Aldosterone Atrial natriuretic peptide

D

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation.

D

A patient who sustained burn injuries is receiving daily treatments. The patient tells the caregiver, "The nurses enjoy hurting me." What should the nurse suspect? Choose the best answer. A. This patient must be having hallucinations. B. This patient might be having schizophrenia. C. This patient has a serious psychiatric condition. D. This is a normal reaction to an extraordinary life event.

D

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% O2using a nonrebreather mask.

D

A patient's family member asks the nurse what SIMV means on the settings of the mechanical ventilator attached to the patient. Which statement is the best response by the nurse? "SIMV is a mode that allows the ventilator to totally control your father's breathing. It will prevent him from hyperventilating or hypoventilating, thus ensuring the best oxygenation." "SIMV provides additional inspiratory pressure so that your father does not have to work as hard to breathe, thus enabling better oxygenation and a quicker recovery with fewer complications." "SIMV is a mode that allows your father to breathe on his own, but the ventilator will control how deep a breath he will receive. The ventilator can sense when he wants a breath and it will deliver it." "SIMV is a mode that allows your father to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator will breathe for him."

D

After change-of-shift report, which patient should the progressive care nurse assess first? a. Patient who was extubated this morning and has a temperature of 101.4°F (38.6°C) b. Patient with bilevel positive airway pressure (BiPAP) for obstructive sleep apnea and a respiratory rate of 16 c. Patient with arterial pressure monitoring who is 2 hours post-percutaneous coronary intervention and needs to void d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 101 sec

D

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Assess mucous membranes. c. Monitor daily weight. d. Measure hourly urine output.

D

Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. c. increase the respiratory rate. b. increase the tidal volume. d. decrease the respiratory rate.

D

The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? a. The RN increases the FIO2 to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN asks for assistance to resecure the endotracheal tube. d. The RN positions the patient with the head of bed at 10 degrees.

D

The nurse has just finished drawing blood from the patient's arterial line in the intensive care unit. The nurse observes the arterial line waveform shows a flat line. Which nursing action is the priority? Reboot the monitor by doing a hard shut-off. Change the transducer setup to ensure patent equipment. Notify the physician on call that no dicrotic notch is visible. Verify the stopcock is open from the patient to the transducer.

D

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops a. O2 saturation of 93%. b. green nasogastric tube drainage. c. respirations of 20 breaths/minute. d. increased jugular venous distention.

D

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods

D

The nurse is monitoring constant hemoglobin (SpO 2) levels for a patient. What is the normal range of SpO 2, which indicates that the saturation pressure of oxygen in this patient is adequate? 80-85% 85-90% 90-95% 95-100%

D

The nurse is teaching the patient's caregiver about receiving positive pressure ventilation. What movements should the nurse tell the caregiver to avoid doing to the patient? Arm circles Knee bends Quadriceps setting External rotation of the hip

D

The nurse responds to a ventilator alarm and finds the patient lying in bed gasping and holding the endotracheal tube (ET) in her hand. Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

D

When taking care of a patient diagnosed with respiratory failure on a mechanical ventilator, the nurse hears the apnea alarm beeping. What assessment data should be gathered to determine the cause of the alarm? Pain or anxiety Partial ventilator disconnect Secretions, coughing, or gagging Oversedation with opioid analgesics

D

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

D

Which assessment tool is most appropriate for monitoring a patient in the intensive care unit (ICU) for delirium? Pain scale Level of consciousness Glasgow Coma Scale (GCS) Confusion assessment method

D

Which fluid and electrolyte change occurs during the early emergent phase of burn injury? Increased excretion of urine Increased colloidal osmotic pressure Return of interstitial fluid to the vascular space Movement of sodium and water into interstitial fluids

D

Which nursing action is needed when preparing to assist with the insertion of a pulmonary artery catheter? a. Determine if the cardiac troponin level is elevated. b. Auscultate heart sounds before and during insertion. c. Place the patient on NPO status before the procedure. d. Attach cardiac monitoring leads before the procedure.

D

Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac c. gabapentin (Neurontin) b. lorazepam (Ativan) d. hydromorphone (Dilaudid)

D

While assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the balloon is inflated and the monitor shows a a. typical PA pressure waveform. b. tracing of the systemic arterial pressure. c. tracing of the systemic vascular resistance. d. typical PA wedge pressure (PAWP) tracing.

D

What are the three determinants of stroke volume? Heart rate, preload, and afterload Preload, afterload, and contractility Heart rate, preload, and contractility Blood pressure, afterload, and contractility

b

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug? a. Bowel sounds b. Stool occult blood c. Stool frequency d. Abdominal distention

b

When assessing the settings of a patient's ventilator, the nurse knows that which parameter is abnormal? PaO 2 of 66 mm Hg PEEP of 5 cm H 2O Tidal volume of 12 mL/kg Respiratory rate of 20 breaths/minute

c

The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which next action by the nurse is indicated? a. Plan to suction the patient more frequently. b. Decrease the suction pressure to 80 mm Hg. c. Give antidysrhythmic medications per protocol. d. Stop and ventilate the patient with 100% oxygen.

d

To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air. b. inflate the cuff until the pilot balloon is firm on palpation. c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d. inject air into the cuff until a slight leak is heard only at peak inflation.

d

While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate a. preparing the patient for a permanent VAD. b. administering immunosuppressive medications. c. teaching the patient the reason for complete bed rest. d. monitoring the surgical incision for signs of infection.

d