Med Surg Final

The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient? · Insulin · Vitamin K · Lactulose · Lorazepam

Lactulose ABX and lactulose are used.

Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial- and full-thickness burns to half of his left arm, his entire left leg, and his perineum. · 28% · 23.5% · 45.5% · 16%

· 23.5%

Place these pathophysiologic mechanisms of DIC in the order in which they occur. 1. Activation of the fibrinolytic system 2. Breakdown of thrombi; spontaneous hemorrhage 3. Consumption of coagulation factors; failure of regulatory mechanisms 4. Endothelial damage; release of tissue factor 5. Thrombin formation; clots form along epithelial walls · 4, 5, 3, 1, 2 · 4, 1, 3, 2, 5 · 5, 1, 2, 4, 3 · 2, 3, 1, 5, 4

· 4, 5, 3, 1, 2

The nurse is developing a patient education plan for the patient with sickle cell anemia. Hydroxyurea is the medication used in the treatment of the disorder. The nurse would inform the patient that the hydroxyurea may be increased by what dosage until the maximum of 35 mg/kg is reached? · 5 mg/kg every 4 weeks · 10 mg/kg every 8 weeks · 5 mg/kg every 12 weeks · 15 mg/kg every 15 weeks

· 5 mg/kg every 12 weeks The patient is usually started at a dosage of 15 mg/kg orally once a day. The dosage is increased by 5 mg/kg every 12 weeks until 35 mg/kg is reached, provided that the patient's blood count remains within an acceptable range.

The nurse is caring for a patient with disseminated intravascular coagulation (DIC). The nurse knows the patient is at high risk for injury and end-organ damage. Which interventions would be included in the plan of care? (Select all that apply.) · Use an automatic blood pressure cuff. · Administer intravenous fluids. · Monitor intake and output. · Use a high-level suction for oral hygiene. · Obtain laboratory specimens via arterial puncture.

· Administer intravenous fluids. · Monitor intake and output. The administration of intravenous fluids, blood products, and medications is essential to providing adequate hemodynamic support and ensuring adequate tissue oxygenation to combat DIC and prevent end-organ damage. Close monitoring of vital signs, hemodynamic parameters, intake and output, and appropriate laboratory values assists in the administration and titration of appropriate agents.

The nurse is caring for a patient with DIC (Disseminated Intravascular Coagulation). The nurse knows the patient is at high risk for bleeding and injury. Which interventions would be included in the plan of care? (Select all that apply.) · Avoid intramuscular injections. · Use a large gauge intravenous cannula for venipunctures. · Use a soft-bristled toothbrush when providing mouth care. · Use a draw sheet when repositioning the patient in bed. · Shave the patient with an electric shaver only.

· Avoid intramuscular injections. · Use a soft-bristled toothbrush when providing mouth care. · Use a draw sheet when repositioning the patient in bed. · Shave the patient with an electric shaver only.

Which pathophysiologic events contributes to renal failure associated with tumor lysis syndrome? · Hypocalcemia · Elevated white blood cell count · Metabolic acidosis · Crystallization of uric acid in the renal tubules

· Crystallization of uric acid in the renal tubules Uric acid patho: Cell lysis leads to increased levels of purine nucleic acids into circulation that are metabolized to uric acid clinical consequences: Renal failure (uric acid nephropathy) tx options: Hydration, dialysis, xanthine oxidase inhibitors, alkalization of urine, urate oxidase

The nursing management plan for a patient with full-thickness burns includes which intervention? · Daily replacement of autografts · Daily wound care with premedication · Weekly wound care until all eschar is debrided · Surgical skin grafting within 8 hours of admission

· Daily wound care with premedication

A patient has been admitted with tumor lysis syndrome. The nurse understands that this is due which pathophysiologic mechanism? · Destruction of platelets by lymphocytic antibodies · Destruction of malignant cells through radiation or chemotherapy · Formation of heparin antibodies · Damage to the endothelium

· Destruction of malignant cells through radiation or chemotherapy The primary mechanism involved in the development of TLS is the destruction of massive numbers of malignant cells by chemotherapy or radiation therapy

. Which anatomic structures are found in the left lower quadrant? (Select all that apply.) · Distended uterus · Cecum and appendix · Left ureter · Portion of the descending colon · Sigmoid colon

· Distended uterus · Left ureter · Portion of the descending colon · Sigmoid colon

A patient has been admitted with tumor lysis syndrome (TLS). Which laboratory findings would support this diagnosis? (Select all that apply.) · Increased calcium · Decreased potassium · Dysrhythmias · Elevated blood urea nitrogen (BUN) · Elevated creatinine

· Dysrhythmias · Elevated blood urea nitrogen (BUN) · Elevated creatinine increased: potassium, phosphorus, uric acid, BUN, Cr decreased: calcium, creatinine clearance, pH, bicarbonate, PaCO2

A patient has been admitted with sickle cell anemia and is requiring a blood transfusion. The nurse understands that transfusions should be used with caution in this patient because of what complication? · Fluid overload · Iron overload · Vasoocclusive crisis · Stroke

· Iron overload

While palpating a patient's abdomen, the nurse observes the presence of persistent involuntary guarding despite efforts to get the patient to relax. This finding is indicative of which condition? · Gaseous distention · Retroperitoneal bleeding · Peritoneal inflammation · Rebound tenderness

· Peritoneal inflammation Persistent involuntary guarding may indicate peritoneal inflammation, particularly if it continues after relaxation techniques are used.

A patient has been admitted with tumor lysis syndrome (TLS). Which intervention would be incorporated into the plan of care to prevent the metabolic imbalances associated with this disorder? · Give sodium polystyrene sulfonate for hypokalemia. · Keep urine pH below 7.0. · Restrict all oral fluids. · Restrict foods containing potassium.

· Restrict foods containing potassium. Massive destruction of cells releases large amounts of potassium, phosphorus, and nucleic acids, leading to severe metabolic disturbances such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia

The nurse is caring for a patient with sickle cell anemia. The nurse knows the patient is at high risk for injury and end-organ damage. Which instructions should be included in the education plan? (Select all that apply.) · Limit fluids particularly in hot weather. · Use pharmacologic methods of pain management. · Consider genetic screening. · Use nonpharmacologic methods of pain management. · Exercise several times a day.

· Use pharmacologic methods of pain management. · Consider genetic screening. · Use nonpharmacologic methods of pain management. manage pain & SCA is genetic

Sickle cell anemia is the most prevalent in persons of which descent? · West African · Middle Eastern · Pacific Islander · Asian

· West African

The nurse is caring for a patient with acute liver failure. What laboratory value would the nurse expect to decrease in this situation? · Albumin · Total bilirubin · Alkaline phosphatase · Aspartate aminotransferase

Albumin Albumin (3.5-5.5 g/dL) Decreases with hepatocellular injury

A patient is undergoing a hepatobiliary scan to assess the progression of cirrhosis of the liver. The nurse would anticipate which result? · Nonvisualization · Little or no uptake · Increased uptake · Normal uptake

Little or no uptake

A patient was admitted with an abdominal mass. Which assessment technique would the nurse find most useful in detecting this pathologic condition? · Percussion · Palpation · Inspection · Auscultation

Palpation

The nurse has been caring for a patient with liver dysfunction. The practitioner has just performed a liver biopsy at the bedside. Following a liver biopsy, how would the nurse position the patient? · Left side for 2 hours · Right side for 2 hours · Left side for 6 to 8 hours · Right side for 6 to 8 hours

Right side for 2 hours Postprocedure: • Position patient on right side for 2 hours. • Pressure dressing is applied, and the patient is on bedrest for 24 hours. • Observe for the following: --Hemorrhage: hypotension, dyspnea (subphrenic hematoma) --Pneumothorax: dyspnea; chest pain; diminished breath sounds on right; hypoxemia --Sepsis: fever; leukocytosis; rebound tenderness

A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery is a RYGBP. What would be an appropriate response from the nurse? · "It is an esophagectomy performed using the transthoracic approach." · "It is an esophagectomy performed using a transhiatal approach." · "It is a combination of restrictive and malabsorption types of bariatric surgery. · "It is a standard operation for pancreatic cancer."

· "It is a combination of restrictive and malabsorption types of bariatric surgery. The Roux-en-Y gastric bypass (Fig. 21.8D) combines both strategies by creating a small gastric pouch and anastomosing the jejunum to the pouch.

Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? · Daily assessment for proper fit and effectiveness · Removal of splints during showers and dressing changes · Allowing for frequent breaks from splint use · Passive and active range of motion may be used instead of splints

· Daily assessment for proper fit and effectiveness

What is a leading cause of death in the hospitalized burn patient? · Smoke inhalation · Infection · Burn shock · Renal failure

· Infection The burn wound is the most common source of infection in the burn patient.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the practitioner to order for this patient? Select all that apply. · Histamine2 (H2) antagonists · Vasopressin · Heparin · Antacids · Somatostatin · Octreotide

· Vasopressin · Somatostatin · Octreotide Intravenous vasopressin, somatostatin, and octreotide can reduce portal venous pressure and slow variceal hemorrhaging by constricting the splanchnic arteriolar bed.

A patient with multisystem trauma has been in the critical care unit for 2 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication? · Hypovolemic shock · Acute kidney injury · Venous thromboembolism · Malnutrition

· Venous thromboembolism you should already know this

The nurse is assessing a patient with abdominal pain. Which finding should be reported to the practitioner? · Visible peristaltic waves · Hyperresonance of the intestine · High-pitched gurgling sounds in the small intestine · Dull sounds over the liver and spleen

· Visible peristaltic waves In the case of intestinal obstruction, hyperactive peristaltic waves may be observed.

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan? · Diabetes management · Alcohol cessation · Occult blood testing · Anticoagulation management

· Alcohol cessation

Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? · Uncontrolled pain · Hypovolemia · Worsening hypoxemia · Decreased pulmonary compliance

· Decreased pulmonary compliance

Which anatomic structures are found in the right upper quadrant? (Select all that apply.) · Duodenum · Portion of the transverse colon · Liver · Pancreas head · Stomach · Cecum

· Duodenum · Portion of the transverse colon · Liver · Pancreas head

A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason? · Presence of infection · Lack of blood supply · Lack of lymphatic drainage · Contamination of the graft

· Lack of blood supply

The nurse is caring for a critically ill patient who is receiving heparin and understands that the patient is at risk for developing heparin-induced thrombocytopenia (HIT). Which previous medical conditions places this patient at risk for developing HIT? · Sepsis from gram negative bacterial infection · Multiple fractures from Motor Vehicle accident · Cardiac arrest · Community Associated Pneumonia

· Multiple fractures from Motor Vehicle accident

The nurse is working on an organization-wide falls prevention project. The nurse understands that the majority of falls accounting for traumatic injury occur in what population? · Construction workers · Adolescents · Older adults · Young adults

· Older adults No explanation needed

The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which type of trauma is this complication usually associated with? · Liver trauma · Kidney trauma · Orthopedic trauma · Spinal cord trauma

· Orthopedic trauma Fat embolism syndrome can occur as a complication of orthopedic trauma. Fat embolism syndrome appears to develop as a result of fat droplets that leak from fractured bone with embolization of the fat droplets to the lungs.

Which anatomic structures are found in the right lower quadrant? (Select all that apply.) · Sigmoid colon · Portion of the ascending colon · Portion of the descending colon · Distended bladder · Enlarged uterus

· Portion of the ascending colon · Distended bladder · Enlarged uterus

A patient with multisystem trauma has been in the ICU for 6 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include: BP—92/66 mm Hg; HR—118 beats/min; T—38.7°C; and CVP—5 mm Hg. What is the most likely cause of this hemodynamic picture? · Septic shock · Hemorrhagic shock · Cardiogenic shock · Neurogenic shock

· Septic shock A patient with multiple injuries is at risk for development of sepsis and septic shock.

The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? · Zone of coagulation · Peripheral zone · Zone of stasis · Zone of hyperemia

· Zone of coagulation The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the site of least severe damage. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.

A patient was admitted with pancreatitis. The nurse is auscultating the patient's abdomen. How long must the nurse listen to be able to accurately chart that bowel sounds are absent? · 30 seconds · 1 minute · 3 minutes · 5 minutes

5 minutes

Upon auscultation, the nurse hears borborygmi. The nurse suspects the patient may be developing which problem? · An ileus · An intestinal obstruction · Abnormality of blood flow · Peritonitis

An intestinal obstruction Abnormal Abdominal Sounds Sound: Hyperactive bowel sounds (borborygmi): loud gurgles or rushing sounds Cause: Hyperperistalsis due to hunger, gastroenteritis, or an intestinal obstruction (early sign)

The nurse is caring for a patient with gastrointestinal bleeding. The practitioner was unable to locate the bleed with an endoscopy. Which procedure would the nurse expect the practitioner to order next? · Plain abdominal series · Magnetic resonance imaging · Angiogram · Computed tomography

Angiogram Evaluates: • Evaluates portal vasculature • Diagnoses source of GI bleeding • Evaluates cirrhosis, portal hypertension, vascular damage resulting from trauma, intestinal ischemia, and tumors • May be used to treat GI bleeding using vasopressin

The nurse is caring for a patient with an upper gastrointestinal bleed. What procedure would the nurse expect the practitioner to order to confirm this diagnosis? · Endoscopic retrograde cholangiopancreatography (ERCP) · Colonoscopy · Endoscopy · Angiography

Endoscopy Esophagogastroduodenoscopy is used to diagnose esophagitis, esophageal ulcers, esophageal strictures, esophageal varices, hiatal hernia, gastritis, gastric ulcers, pyloric obstruction, pernicious anemia, foreign bodies, or duodenal inflammation or ulcers and to evaluate esophageal or gastric motility, bleeding, lesions, and status of surgical anastomoses

The practitioner has ordered a magnetic resonance imaging (MRI) of the liver. What would the nurse do to prepare the patient for the examination? · Explain the patient must lie still during the procedure. · Explain the patient may experience deep pressure sensation. · Inform the patient that he or she will have to drink contrast. Inform the patient that the procedure will be performed at the bedside.

Explain the patient must lie still during the procedure. Cannot be used in patients with any implanted metallic device, including pacemakers • No special preparation required • Must be able to lie flat and still for 30-60 minutes during the scan; sedation may be necessary.

1. A patient was admitted with pancreatitis. In which order would the nurse perform an assessment of the gastrointestinal system? · Inspection, palpation, percussion, and auscultation · Palpation, percussion, inspection, and auscultation · Inspection, auscultation, percussion, and palpation · Palpation, inspection, auscultation, and percussion

Inspection, auscultation, percussion, and palpation

What intervention should be included in the patient management plan of a patient undergoing an angiogram? · Maintain the patient flat in bed for 24 hours after the procedure. · Insert a nasogastric tube before the procedure. · Administer tap water enemas until clear before the procedure. · Keep the affected extremity straight and immobilized for 6 to 12 hours after the procedure.

Keep the affected extremity straight and immobilized for 6 to 12 hours after the procedure. Postprocedure: • Keep extremity in which catheter was placed immobilized in a straight position for 6-12 hours. • Monitor arterial puncture point for hemorrhage or hematoma. • Monitor neurovascular status of affected limb. • Monitor for indications of systemic emboli.

A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs as a result of what pathophysiologic mechanism? · Uncontrolled hypoglycemia caused by an increased release of insulin · Loss of storage capacity for senescent red blood cells · Premature activation of inactive digestive enzymes, resulting in autodigestion · Release of glycogen into the serum, resulting in hyperglycemia

Premature activation of inactive digestive enzymes, resulting in autodigestion In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, leading to autodigestion of pancreatic tissue

Preprocedural teaching of a patient undergoing a liver scan should include which instruction? · Drink at least 500 mL of fluids before the procedure. · Remain flat in bed for 12 hours after the procedure. · Stay flat and still during the procedure. · Sedation will be provided during the procedure.

Stay flat and still during the procedure.

The practitioner has ordered a test for steatorrhea. The nurse knows this is determined by which laboratory study? · Gastric acid stimulation · Urea breath test · Culture and sensitivity · Stool studies

Stool studies findings: bacteria, fat (steatorrhea), pus, blood, parasites

A patient has been admitted with abdominal pain. The practitioner suspects the patient has gallstones. Which diagnostic procedure would the nurse expect the practitioner to order to confirm this diagnosis? · Ultrasonography · Abdominal radiography · Angiography · Liver scan

Ultrasonography

The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information? · "Autografts are procured from both live and deceased donors." · "Autografts can be placed at the bedside or in the operating room." · "Autografts can transmit disease and be rejected." · "Autografts provide permanent coverage and are the least expensive."

· "Autografts provide permanent coverage and are the least expensive." An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient's burn wound to provide permanent coverage of the wound. Autografts are the only grafts that provide permanent wound coverage.

A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What would be an appropriate response from the nurse? · "This procedure is usually performed for cancer of the proximal esophagus and gastroesophageal junction." · "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." · "This procedure is usually performed for cancer of the pancreatic head." · "The procedure is usually performed for varices of the distal esophagus and gastroesophageal junction."

· "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction.

Using the Parkland formula for fluid resuscitation and knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior torso, perineum, and entire right leg. · 2775 mL · 5550 mL · 8325 mL · 11,100 mL

· 5550 mL 4mL X 37(%) X 75kg= 11,100 11,100/2= 5550mL

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement according to ABA consensus (3mL)? · 5738 mL of Lactated Ringer solution (LR) for the first 8 hours; then 5738 mL of LR over the next 16 hours · 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic NS over the next 16 hours · 11,475 mL of dextran evenly divided over the first 24 hours · 11,475 mL of LR evenly divided over the first 24 hours

· 5738 mL of Lactated Ringer solution (LR) for the first 8 hours; then 5738 mL of LR over the next 16 hours 3mL X 45 (%) X 85kg= 11,475mL 11,475/2=5738mL 50% of fluid over first 8 hr; 50% of fluid over next 16 h

A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? · Ask the practitioner to order a STAT chest radiograph. · Apply a pulse oximeter to one of his unburned fingers. · Call the local hyperbaric chamber to check on its availability. · Administer 100% oxygen via a nonrebreathing mask.

· Administer 100% oxygen via a nonrebreathing mask. The treatment of choice for carbon monoxide poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation.

A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control? · Administer analgesics only as needed. · Administer analgesics around the clock. · Educate the patient and family on lifestyle changes. · Teach relaxation and distraction techniques.

· Administer analgesics around the clock. Pain management is a major priority in acute pancreatitis. Administration of around-the-clock analgesics to achieve pain relief is essential.

A patient with severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize secondary brain injury? · Hyperventilate the patient to keep PCO2 less than 30. · Restrict fluids to keep central venous pressure less than 6 cm H2O. · Maintain the patient's body temperature more than 37.5°C. · Administer fluids to keep the mean arterial pressure greater than 60 mm Hg.

· Administer fluids to keep the mean arterial pressure greater than 60 mm Hg. Heart rate and blood pressure are continually monitored, with the goal of achieving MAP greater than 60 mm Hg (minimum) to ensure adequate perfusion to the brain. Isotonic IV fluids (e.g., 0.9% normal saline) and vasopressors may be required if target MAP is not achieved.

An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate? · Airway assessment must incorporate cervical spine immobilization. · Hyperextension of the neck is the only acceptable technique. · Flexion of the neck protects the patient from further injury. · Airway patency takes priority over cervical spine immobilization.

· Airway assessment must incorporate cervical spine immobilization. Airway placement must incorporate cervical spine immobilization

A patient was admitted with pancreatitis. Which laboratory value would the nurse expect the practitioner to order to confirm this diagnosis? · Bilirubin · Amylase · Lactate dehydrogenase · Ammonia

· Amylase Serum amylase (25-125 units/mL) Elevated levels with pancreatic inflammation

The nurse is caring for a patient with disseminated intravascular coagulation (DIC). The practitioner has ordered "bleeding precautions." Which interventions should be included in the patient's plan of care? (Select all that apply.) · Apply firm pressure to all puncture sites. · Initiate fall precautions. · Apply heat to areas of trauma. · Use an automatic blood pressure cuff. · Administer medications via IM injection.

· Apply firm pressure to all puncture sites. · Initiate fall precautions. Handle the patient gently. •Use a draw sheet when repositioning the patient in bed. • Instruct the patient to notify the nurse immediately if bleeding or bruising is noted. Protect the patient from trauma. • Avoid rectal temperatures, enemas, and suppositories. • If suppositories are prescribed, lubricate liberally and administer with caution. • Initiate fall precautions. • Instruct the patient to notify the nurse immediately if any trauma occurs. Avoid IM injections and venipunctures. • If necessary, use a small-gauge needle or IV cannula Apply firm pressure to any puncture sites for at least 10 min or until site no longer oozes blood. Apply ice to areas of trauma. Avoid the use of manual or automatic blood pressure cuff. • If necessary, remove cuff immediately after using it. • Do not leave cuff on the patient. Observe IV sites every few hours for bleeding. Shave the patient with an electric shaver only. Use a soft-bristled toothbrush when providing mouth care. Test urine and stool for occult blood as ordered.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? · Clean the wounds and remove blisters. · Assess the airway and provide 100% oxygen. · Place a urinary drainage catheter and assess for myoglobin. · Place a central intravenous access and provide antibiotics.

· Assess the airway and provide 100% oxygen. ABC's...

A patient is admitted to the ICU for observation of his grade II splenic laceration. Which signs and symptoms suggest that the patient has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock? · BP, 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/hr; skin that is pink, warm, and dry with capillary refill of 3 seconds · BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused · BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/hr; pale, cool, dry skin; alert and oriented · BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/hr; flushed, warm, diaphoretic skin; agitated and confused

· BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused

Major trauma patients are at high risk of developing deep venous thrombosis and pulmonary embolism. The nurse understands that trauma patients are at risk due to which factors? (Select all that apply.) · Blood stasis · Hypernatremia · Injury to the intimal surface of the vessel · Hyperosmolarity · Hypercoagulopathy · Immobility

· Blood stasis · Injury to the intimal surface of the vessel · Hypercoagulopathy · Immobility Patients with major trauma are at very high risk for VTE. Factors that form the basis of VTE pathophysiology are common in trauma, including endothelial injury (as a result of trauma), hypercoagulopathy (as a result of trauma-induced coagulopathy), and blood stasis (as a result of immobility).

A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. The nurse suspects the patient may have which type of injury? · Posterior cord syndrome · Brown- Séquard syndrome · Diffuse axonal injury · Central cord syndrome

· Central cord syndrome •Central cord syndrome is associated with cervical hyperextension-hyperflexion injury and hematoma formation in the center of the cervical cord. This injury produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Bowel and bladder dysfunction may be present.

Patients immobilized because of spinal trauma are at a high risk for contractures. The nursing management plan for these patients should include which preventive measures? (Select all that apply.) · Consultation by PT and OT early in the treatment of the patient · Turning and repositioning the patient every 2 hours as ordered by the practitioner · Range of motion exercises 1 month after the spine has been stabilized · Removal of splints every 4 hours and at bedtime · Hand splints for patients with paraplegia · Hand and foot splints for patients with quadriplegia

· Consultation by PT and OT early in the treatment of the patient · Turning and repositioning the patient every 2 hours as ordered by the practitioner · Hand and foot splints for patients with quadriplegia

A patient was admitted with gram-negative sepsis a few days ago. Today the nurse observes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. What other laboratory value would be valuable in definitively diagnosing the patient's condition? · Fibrin split products · D-Dimer level · Bleeding time · White blood cell count

· D-Dimer level Another key laboratory test used to evaluate the degree of clot dissolution—and the severity of the coagulopathy—is the D-dimer level. D-Dimers exclusively indicate clot degradation because, in contrast to fibrin degradation products, which also result from the breakdown of free circulating fibrin, D-dimers result only from dissolution of clots

A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? (Select all that apply.) · Dark tea-color urine · Decreased urine output · Decreased oxygen saturation · Diminished pulses · Increased serum creatine kinase level

· Dark tea-color urine · Decreased urine output · Increased serum creatine kinase level Dark tea-colored urine suggests myoglobinuria. Increased creatine kinase levels are associated with muscle damage and renal failure. Urine output and serial creatine kinase levels should be monitored.

The nurse is caring for a patient with blunt abdominal trauma. The nurse understands that the patient is at risk for abdominal compartment syndrome. Which findings would the nurse expect to observe as evidence of this complication? (Select all that apply.) · Decreased cardiac output · Increased peak pulmonary pressures · Decreased urine output · Hypoxemia · Bradycardia

· Decreased cardiac output · Increased peak pulmonary pressures · Decreased urine output · Hypoxemia Clinical manifestations of abdominal compartment syndrome include decreased cardiac output, decreased tidal volumes, increased peak pulmonary pressures, decreased urine output, and hypoxia.

A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record? · Superficial partial-thickness burn · Moderate partial-thickness burn · Deep dermal partial-thickness burn · Full-thickness burn

· Deep dermal partial-thickness burn A deep-dermal partial-thickness burn usually is not characterized by blister formation. Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure.

The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse knows that pulmonary embolism is a serious complication of HIT. Which findings would alert the nurse to the presence of this complication? · Blanching of fingers and toes and loss of peripheral pulses · Chest pain, pallor, and confusion · Headache, impaired speech, and loss of motor function · Dyspnea, pleuritic pain, and rales

· Dyspnea, pleuritic pain, and rales Dyspnea, pleuritic pain, rales, chest pain, chest wall tenderness, back pain, shoulder pain, upper abdominal pain, syncope, hemoptysis, shortness of breath, wheezing

A patient is admitted with acute abdominal trauma. The patient has a positive Focused Assessment with Sonography for Trauma (FAST scan) and is hemodynamically unstable. What procedure should the nurse anticipate next? · Emergency surgery · Diagnostic peritoneal lavage (DPL) · Computed tomography scan · Intra-abdominal pressure monitoring

· Emergency surgery Hemodynamically unstable patients with a positive FAST examination generally undergo emergency surgery to achieve hemostasis.

Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage? · Positioning the patient in a high-Fowler's position · Ensuring the patient has a patent airway · Irrigating the nasogastric tube with iced saline · Maintaining venous access so that fluids and blood can be administered

· Ensuring the patient has a patent airway Priorities in the medical management of a patient with GI hemorrhage include airway protection; fluid resuscitation to achieve hemodynamic stability; correction of co-morbid conditions, if possible (e.g., coagulopathy); therapeutic procedures to control or stop bleeding; and diagnostic procedures to determine the exact cause of the bleeding

A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this diagnosis? Select all that apply. · Epigastric and abdominal pain · Nausea and vomiting · Diaphoresis · Jaundice · Hyperactive bowel sounds · Fever

· Epigastric and abdominal pain · Nausea and vomiting · Diaphoresis · Jaundice · Fever Pain --Location: left upper quadrant or midepigastrium radiating to the back • Nausea and vomiting • Flushing and diaphoresis • Dyspnea • Low-grade fever • Abdominal distention • Abdominal tenderness and guarding • Abdominal tympany • Hypoactive or absent bowel sounds • Jaundice • Palpable abdominal mass • Ecchymoses or bluish discoloration of the flanks (Grey Turner sign) and/or the umbilical area (Cullen sign) • Basilar crackles • Tachypnea • Tachycardia • Hypotension

A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? · Escharotomy · Silver Sulfadiazine application · Splint application · Xenograft application

· Escharotomy An escharotomy may be required to restore arterial circulation and to allow for further swelling

The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse understands that this disorder has which characteristic? · Formation of thrombi · Spontaneous epistaxis · Elevated prothrombin times · Massive peripheral ecchymoses

· Formation of thrombi The resultant formation of fibrin- and platelet-rich thrombi is the primary characteristic of HIT that distinguishes it from other forms of thrombocytopenia and gives rise to its more descriptive name: white clot syndrome

The nurse has been caring for a patient with a liver abscess. Upon auscultation of the right upper quadrant, the nurse would expect to hear which type of sounds? · Bruits · Friction rub · Hypoactive · Hyperactive

· Friction rub Sound: Peritoneal friction rubs: rough, grating sound heard over the liver or spleen synchronous with respiration Cause: Inflammation of the peritoneal covering of an organ due to tumors, infections, or abscesses

The nurse is caring for a patient with acute liver failure. The practitioner asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom? · Inflate a blood pressure cuff on the patient's arm. · Have the patient bring the knees to the chest. · Have the patient extend the arms and dorsiflex the wrists. · Dorsiflex the patient's foot.

· Have the patient extend the arms and dorsiflex the wrists. Asterixis is best recognized by downward flapping of the hands when the patient extends the arms and dorsiflexes the wrists.

A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms? · Metabolic acidosis and hypovolemia · Decreasing hemoglobin and hematocrit · Hyperkalemia and hypernatremia · Hematemesis and melena

· Hematemesis and melena Hematemesis (bright red or brown, "coffee grounds" emesis), hematochezia (bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan? · Continue as planned; everything looks good. · IV rate should be decreased and colloids started. · IV rate should be increased and fluid status closely watched. · Fluids should be switched to packed red blood cells.

· IV rate should be increased and fluid status closely watched. The rate of fluid administration is adjusted according to the individual's response, which is determined by monitoring urine output, heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient's intake and output is imperative to ensure that he or she is appropriately resuscitated.

A patient has been admitted with a pulmonary contusion. Which finding will cause a nurse to suspect that the patient's condition is deteriorating? · Increased bruising on the chest wall · Increased need for pain medication · The development of respiratory alkalosis · Increased work of breathing

· Increased work of breathing A contusion manifests initially as a hemorrhage, followed by alveolar and interstitial edema. The edema can remain localized in the contused part or can spread to other areas of the lung. Inflammation affects exchange of gas across the alveolar-capillary membrane. As inflammation and edema increase, a decrease in respiratory compliance, increased resistance, and decreased pulmonary blood flow may occur. These processes result in a ventilation-perfusion imbalance that results in progressive hypoxemia and poor ventilation

A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? · Intravenous opiates and assessment of pulses in both arms · Oral anti-inflammatory drugs and preparation for insertion of an arterial line · Measurement of sedimentation rate and systemic antibiotics · Application of splints and initiation of total parenteral nutrition

· Intravenous opiates and assessment of pulses in both arms Neurovascular integrity of extremities with circumferential burns must be assessed every hour for the first 24 to 48 hours using the six "Ps": pulselessness, pallor, pain, paresthesia, paralysis, and poikilothermy.

Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related to what physiologic change? · Deterioration of cerebral and motor skills · Poor vision and hearing · Diminished pain perception · Limited physiologic reserve

· Limited physiologic reserve

A patient was admitted with gram-negative sepsis a few days ago. Today the nurse notes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. The nurse places highest priority on which treatment goal? · Maintain adequate organ perfusion. · Suppress antibody response that is destroying platelets. · Treat life-threatening metabolic disturbances. · Begin hypothermic therapy to prevent cerebral hemorrhage.

· Maintain adequate organ perfusion. After DIC is identified, maintaining organ perfusion and slowing consumption of coagulation factors are paramount to achieving a favorable outcome

A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor vehicle crash. The patient's plan of care would involve which nursing action? · Perform neurologic assessments once a shift. · Obtain a computed tomography (CT) scan every day. · Monitor blood pressure and temperature every hour. · Initiate warming measures to keep temperature greater than 37.5°C.

· Monitor blood pressure and temperature every hour. •Treatment of DAI includes support of vital functions and maintenance of ICP within normal limits.

A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? Select all that apply. · Administer benzodiazepines for agitation. · Monitor oxygen saturation. · Initiate an insulin drip for hyperglycemia. · Monitor serum electrolyte levels. · Assess for signs of cerebral edema.

· Monitor oxygen saturation. · Monitor serum electrolyte levels. · Assess for signs of cerebral edema. Continuous pulse oximetry monitoring and arterial blood gas analysis are helpful in assessing adequacy of respiratory efforts. A thorough neurologic assessment should be performed at least every hour, with changes reported immediately

The nurse is caring for a critically ill patient who is receiving heparin and understands that the patient is at risk for developing heparin-induced thrombocytopenia (HIT). Which intervention would be included into the patient's plan of care to monitor for this potential complication? · Monitor D-dimer levels every 5 to 10 hours from day 2 to day 5. · Monitor prothrombin time (PT) every 5 to 14 hours from day 2 to day 12. · Monitor platelet count every 2 or 3 days from day 4 to day 14. · Monitor international normalized ratio (INR) every 5 days from day 10 to day 30.

· Monitor platelet count every 2 or 3 days from day 4 to day 14. Current guidelines suggest that platelet count monitoring be performed every 2 or 3 days from day 4 to day 14 for high-risk patients

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care? · Monitor the patient for hypovolemic shock from plasma volume depletion. · Observe the patient for hypoglycemia and hypercalcemia. · Initiate enteral feedings after the nasogastric tube is placed. · Place the patient on a fluid restriction to avoid the fluid sequestration.

· Monitor the patient for hypovolemic shock from plasma volume depletion. The most serious complications are hypovolemic shock, acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and GI hemorrhage. Hypovolemic shock is the result of relative hypovolemia resulting from third spacing of intravascular volume and vasodilation caused by the release of inflammatory immune mediators.

A patient is admitted with a blunt cardiac injury (BCI) with no evidence of rupture. The nursing management plan should include which intervention? · Administer nitroglycerine for chest pain as needed. · Monitor the patient for new onset dysrhythmias. · Monitor serial biomarkers for evidence of further damage. · Do not administer antidysrhythmic medications as they are ineffective.

· Monitor the patient for new onset dysrhythmias. Medical management is aimed at preventing and treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of antidysrhythmic medications.

A patient has sustained an epidural hematoma after a 10-foot fall from a roof. The nurse understands that an epidural hematoma is a condition that has which characteristic? · Most often associated with middle meningeal artery lacerations · Collection of blood between the dura mater and the arachnoid membrane · Associated with a permanent loss of consciousness · Signs and symptoms include bilateral pupil dilation

· Most often associated with middle meningeal artery lacerations EDHs are most often associated with skull fractures and middle meningeal artery lacerations (two-thirds of patients) or skull fractures with venous bleeding.

A nurse and a new graduate nurse are discussing the secondary survey of the trauma patient. The nurse asks the new graduate to identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the information? · Check circulatory status. · Check electrolyte profile. · Insert a urinary catheter. · Obtain patient history.

· Obtain patient history. The patient history is also an important aspect of the secondary survey. The patient's pertinent past history can be assessed by use of the mnemonic AMPLE: A: Allergies M: Medications currently used P: Past medical illnesses/Pregnancy L: Last meal E:Events/Environment related to the injury

A patient has been admitted with a flail chest. What findings would the nurse expect to observe supporting this diagnosis? · Tracheal deviation toward the unaffected side · Jugular venous distention · Paradoxical respiratory movement · Respiratory alkalosis

· Paradoxical respiratory movement A flail chest is a clinical diagnosis wherein the so-called flail segment (or floating segment) moves paradoxically compared with the rest of the chest wall

The nurse is caring for a patient with extensive trauma to the lower extremities. The nurse understands that patient is at risk for compartment syndrome. Which findings would the nurse expect to observe as evidence of this complication? (Select all that apply.) · Paresthesia · Decreased pulses · Pain in the affected extremity · Swelling in the affected extremity · Decreases capillary refill

· Paresthesia · Pain in the affected extremity · Swelling in the affected extremity Clinical manifestations of compartment syndrome include obvious swelling and tightness of a limb, paresthesia, and extreme pain in the affected extremity.7 Diminished pulses and decreased capillary refill do not reliably identify compartment syndrome, because they may be intact until after irreversible damage has occurred. Elevated intracompartmental pressures confirm the diagnosis.

A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? · Superficial (first-degree) burn · Partial-thickness (second-degree) burn · Deep dermal partial-thickness (second-degree) burn · Full-thickness (third-degree) burn

· Partial-thickness (second-degree) burn A partial-thickness (second-degree) burn involves all the epidermis and part of the underlying dermis.5 These burns usually are caused by brief contact with flames, hot liquid, or exposure to dilute chemicals (Fig. 25.5). A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. These burns blanch painfully. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid lifts off the thin, damaged epidermis, causing blister formation

A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage? · Stress ulcers · Peptic ulcers · Nonspecific erosive gastritis · Esophageal varices

· Peptic ulcers Peptic ulcer disease (i.e., gastric and duodenal ulcers), which results from the breakdown of the gastromucosal lining, is the leading cause of upper GI hemorrhage, accounting for approximately 40% of cases

The nurse is caring for a patient with an upper gastrointestinal bleed. The practitioner has just performed an endoscopy at the bedside. What complications would the nurse monitor the patient for after the procedure? (Select all that apply.) · Perforation · Hemorrhage · Oversedation · Constipation · Aspiration

· Perforation · Hemorrhage · Oversedation · Aspiration Monitor closely after procedure for clinical indications of perforation or hemorrhage. oversedation and aspiration bc sedation may be used

According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that apply.) · Arms · Perineum · Chest · Shoulder joint · Genitalia · Face · Hands

· Perineum · Shoulder joint · Genitalia · Face · Hands Burns of face, hands, feet, genitalia, perineum, or major joints that may result in cosmetic or functional disability

What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? · The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. · A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. · Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.

· Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism? · Portal hypertension · Superficial mucosal erosions · Breakdown the mucosal resistance · Inflammation and ulceration

· Portal hypertension Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop as a result of portal hypertension caused by hepatic cirrhosis

The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention would have the highest priority? · Preventing atelectasis · Managing pain · Promoting ambulation · Preventing infection

· Preventing atelectasis The nursing management plan for the patient who has had GI surgery incorporates a variety of patient problems (Box 21.18). Nursing priorities are directed toward (1) optimizing oxygenation and ventilation, (2) providing comfort and emotional support, and (3) maintaining surveillance for complications Nursing interventions in the postoperative period are focused on promoting ventilation and adequate oxygenation and preventing complications such as atelectasis and pneumonia.

A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen? · Allows for administration of tube feeding. · Allows for testing of gastric secretions. · Prevents tube from adhering to the gastric wall. · Prevents the tube from advancing.

· Prevents tube from adhering to the gastric wall. The Salem sump has one lumen that is used for suction and drainage and another that allows air to enter the patient's stomach and prevents the tube from adhering to the gastric wall and damaging the mucosa.

A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing which is characterized by rapid synthesis of collagen. What phase is the patient in? · Wound phase · Inflammatory phase · Proliferative phase · Maturation phase

· Proliferative phase

A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury? · Rhabdomyolysis · Stress ulcers · Pneumothorax · Venous thromboembolism

· Rhabdomyolysis The electrical burn process can result in a profound alteration in acid-base balance and rhabdomyolysis resulting in myoglobinuria, which poses a serious threat to kidney function.

What is the most common cause of disseminated intravascular coagulation (DIC)? · Sepsis caused by gram-positive organisms · Sepsis caused by gram-negative organisms · Sickle cell anemia · Burns

· Sepsis caused by gram-negative organisms

A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? Select all that apply. · Calcium · Serum amylase · Serum glucose · Potassium · WBC · Serum lipase

· Serum amylase · Serum glucose · WBC · Serum lipase Elevated: Serum amylase Urine amylase Serum lipase Serum triglycerides Cross-reactive protein Glucose White blood cell count Prothrombin time (Prolonged) Decreased: Calcium Magnesium Potassium May be elevated: Bilirubin Liver enzymes Arterial blood gases: Hypoxemia Metabolic acidosis

A patient is admitted with symptoms of a low-grade fever, joint pain, tachycardia, hepatomegaly, photophobia, and an inability to follow commands. The patient is becoming more agitated and complaining of pain. The nurse suspects that the patient has which disorder? · Tumor lysis syndrome · Heparin-induced thrombocytopenia · Sickle cell anemia · Disseminated intravascular coagulation

· Sickle cell anemia The patient may present with a low-grade fever, bone or joint pain, pinpoint pupils, inability to follow commands, photophobia, tachycardia, tachypnea, decreased respiratory excursion, hepatomegaly, nonpalpable spleen, and pretibial ulcers

Which topical antimicrobial agent is commonly used as a broad-spectrum agent and is activated by the wound moisture? · Silver · Bacitracin · Mafenide acetate cream · Silver sulfadiazine

· Silver Silver has long been used for the treatment of wounds because of its broad-spectrum bacteriostatic properties against gram-negative and gram-positive bacteria.27 Silver has minimal side effects and minimal bacterial resistance. The wound moisture activates the silver and releases it into the wound.

A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery? · Large doses of opioids given intramuscularly · Intravenous opioids used in combination with oral antidepressants · Large doses of opioids given subcutaneously · Small doses of intravenous opioids titrated to effect

· Small doses of intravenous opioids titrated to effect Initially after burn injury, opiates are administered intravenously in small doses and titrated to effect.

Which anatomic structures are found in the left upper quadrant? (Select all that apply.) · Stomach · Spleen · Portion of the transverse and descending colon · Head of the pancreas · Body of the pancreas

· Stomach · Spleen · Portion of the transverse and descending colon · Body of the pancreas

The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence? · Crackles in the lung bases · Subcutaneous emphysema · Incisional bleeding · Absent of bowel sounds

· Subcutaneous emphysema In a patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck

What anatomic structures are part of inspection of the gastrointestinal system? (Select all that apply.) · Teeth · Gums · Skin over the abdomen · Spleen · Abdomen

· Teeth · Gums · Skin over the abdomen · Abdomen Inspection of the patient focuses on three priorities: (1) observation of the oral cavity, (2) assessment of the skin over the abdomen, and (3) evaluation of the shape of the abdomen.

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse suspects these findings are indicative of which disorder? · Tension pneumothorax · Cardiac tamponade · Simple pneumothorax Ruptured diaphragm

· Tension pneumothorax •Clinical manifestations: --dyspnea, tachycardia, hypotension, sudden chest pain, tracheal deviation

A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center? · The size and depth of burn injury and the burning agent · The age and present medical history of the patient · The depth of the burn injury and the presence of soot in the sputum · The medical history of the patient and the size and depth of the burn injury

· The medical history of the patient and the size and depth of the burn injury

A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted a chest tube on the left side and 1800 mL of blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure? · Thoracotomy · Pericardiocentesis · Splenectomy · Pneumonectomy

· Thoracotomy Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/hr for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are accompanying injuries to major cardiovascular

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable what cause? · Blood loss associated with burns and pain. · Hemodynamic stability related to adequate fluid resuscitation. · Over-resuscitation related to overestimation of the burn area involved. · Under-resuscitation because of probable wound conversion.

· Under-resuscitation because of probable wound conversion. Underresuscitation may result in inadequate cardiac output, leading to inadequate organ perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury.

A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information? · Used to assess respiratory status · Used to assess circulatory status · Used to assess pain status · Used to assess level of consciousness

· Used to assess level of consciousness The AVPU method can be used to quickly describe the patient's level of consciousness: A: Alert V: Responds to Verbal stimuli P: Responds to Painful stimuli U: Unresponsive