Med Surg Final Exam

1. The correct order of actions in the management of the postoperative surgical trauma patient who has been admitted to the critical care unit after surgery is (Put a comma and space between each answer choice.) a. Connect the patient to bedside monitor and mechanical ventilator. b. Obtain vital signs, rhythm, oxygen saturation, and neurological status. c. Assess airway, breathing, and circulation. d. Reassess and evaluate patency of IV lines, and adjust rate of fluid administration as ordered.

ANS: C, A, B, D The initial intervention upon admission to the critical care unit is a rapid assessment of airway, breathing, and circulation. The nurse quickly connects the patient to the bedside monitor and ventilator, and completes an assessment of vital signs, cardiac rhythm, pulse oximetry reading, level of consciousness, and pupil reactivity. The nurse reassesses IV access and evaluates the patency of IV catheters, because they may have become dislodged during transport. Calculation of medication dosages and rates is completed as part of the initial assessment. Once the assessment and initial interventions have been completed, the family is contacted to see the patient. DIF: Cognitive Level: Analysis OBJ: Explain the priorities of care for the postoperative surgical patient. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

1. What is the correct priority order of actions in prehospital primary survey for burn injuries? (Put a comma and space between each answer choice.) a. Assess ABCs and cervical spine. b. Provide oxygen therapy if smoke inhalation is suspected. c. Make rapid head-to-toe assessment to rule out additional trauma. d. Stop the burning process and prevent further injury.

ANS: D, A, B, C Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries. DIF: Cognitive Level: Analysis OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. Prevention of hypothermia is crucial in caring for trauma patients. The correct order of actions for the preparation for the trauma patient is (Put a comma and space between each answer choice.) a. Remove wet clothing. b. Warm fluids and blood products before administration. c. Cover the patient with an external warming device. d. Warm the ED or intensive care unit (ICU) room before the patient's arrival.

ANS: D, A, C, B Before arrival to the ED or ICU, the receiving room needs to be warmed. The patient's clothing is removed, and he or she should be covered to prevent external loss of heat. An external warming device needs to be immediately available for warming the patient after arrival. Fluids that are administered should be warmed via active internal devices. DIF: Cognitive Level: Synthesis OBJ: Discuss prehospital care, emergency care, and resuscitation of the trauma patient. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

16. What is the priority nursing intervention for a patient who experienced a chemical burn injury? a. Remove the patient's clothes and flush the area with water. b. Apply saline compresses. c. Contact a poison control center for directions on neutralizing agents. d. Remove all jewelry.

ANS: A As long as the chemical remains in contact with the skin, burn damage will result. Priority interventions are to remove the patient's clothes, brush loose chemical away from the skin and apply water for at least 30 minutes. Water needs to washed away from the body, not be applied as compresses. Contacting poison control may be helpful in obtaining more information on the systemic effects of the chemical, but it is not a priority intervention. Jewelry should be removed, but this is not as high a priority as removing the chemical and stopping the chemical burning process through continuous flushing with water. DIF: Cognitive Level: Application OBJ: Describe the pathophysiology of burns. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

3. An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a. Level I b. Level II c. Level III d. Level IV

ANS: A Because the patient is hypotensive and was unrestrained, the patient is at higher risk for more severe injuries related to the mechanism of injury; thus, treatment should occur at a level I trauma center. Patients with less severe injuries can be treated at lower level trauma centers. DIF: Cognitive Level: Application OBJ: Discuss prehospital care, emergency care, and resuscitation of the trauma patient. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment

24. The patient is admitted with reports of chronic fatigue, frequent nosebleeds, and shortness of breath. The nurse notices that the patient is tachycardic and has multiple bruises and petechiae on body and arms. The patient also complains of. The nurse should initially review which diagnostic study? a. Complete blood count, including platelet count b. Hemoglobin and hematocrit c. Electrolyte values d. Blood culture results

ANS: A In addition to the general symptoms of anemia, unique disorders have their own classic clinical features. The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. The CBC with differential, which includes a platelet count, would allow for evaluation of all aspects of aplastic anemia. Hemoglobin and hematocrit help to assess for blood loss, but assessment of cause (e.g., low platelets) is more important. Electrolyte values and blood culture results are not relevant to this scenario. DIF: Cognitive Level: Analysis OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

7. The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a. Placement of an intraosseous catheter b. Placement of a central line placement c. Insertion of a femoral catheter by a trauma surgeon d. Rapid transfer to the operating room

ANS: A Infusion of volume is required for optimal fluid resuscitation and may be achieved through large caliber venous cannulation or intraosseous access. A central line or femoral vein access may be obtained by the physician, but the procedure requires time. Transport to the operating room is not a priority in the goal to obtain intravenous access for fluid resuscitation. DIF: Cognitive Level: Application OBJ: Describe prehospital care, emergency care, and resuscitation of the trauma patients. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

27. The patient has yellow skin and low hemoglobin and hematocrit levels. The nurse should expect which lab result? a. An elevated bilirubin level b. A low reticulocyte count c. A low platelet count d. Low white blood cell

ANS: A Laboratory findings in anemia include a decreased RBC count and decreased hemoglobin and hematocrit values. The reticulocyte count is usually increased, indicating a compensatory increased RBC production with release of immature cells. This patient's jaundice is indicative of hemolytic anemia. Patients with hemolytic anemia also have an increased bilirubin level. In sickle cell disease, a stained blood smear reveals sickled cells. In aplastic anemia, the reticulocyte, platelet, RBC, and WBC counts are decreased because the marrow fails to produce any cells. DIF: Cognitive Level: Analysis OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

8. The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which possible complication? a. Central nervous system deficits b. Contractures c. Infection d. Stress ulcers

ANS: A Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits. Contractures, infection, and stress ulcer risks are no greater than with other causes of burn injury. DIF: Cognitive Level: Comprehension OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

42. The patient with a platelet count of 35,000/microliter is ordered the administration of 10 units of single-donor platelets. After transfusion, the nurse can expect the patient's platelet count to be at what level? a. Between 85,000/microliter and 135,000/microliter b. Between 50,000/microliter and 75,000/microliter c. Greater than 150,000/microliter d. Between 150,000/microliter and 185,000/microliter

ANS: A Medical treatment of thrombocytopenia includes infusions of platelets. Patients who require multiple platelet transfusions should be evaluated for single-donor platelet products, which permit administration of 6 to 10 units of platelets with exposure to the antigens of only one person. For every unit of single-donor platelets, the platelet count should increase by 5000 to 10,000/microliter. DIF: Cognitive Level: Analysis OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

11. What is the process in which antibody and complement proteins attach to the target cell and enhance the phagocyte's ability to engulf the target cell? a. Opsonization b. Phagocytosis c. The lymphoreticular system d. The portal circulation

ANS: A Neutrophils are attracted to and migrate to areas of inflammation or bacterial invasion, where they ingest and kill invading microorganisms by phagocytosis. Once phagocytes have been attracted to an area by the release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the target cell and enhance the phagocyte's ability to engulf the target cell. When infectious organisms escape the local phagocytic responses, they may be engulfed and destroyed in a similar fashion by the tissue macrophages within the lymphoreticular organs. The portal circulation of the spleen and liver filters the majority of blood, where infectious organisms can be removed before infecting the tissues. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Step: Assessment MSC: NCLEX: Physiological Integrity

6. An autograft is used to optimally treat a partial- or full-thickness wound that meets what criteria? (Select all that apply.) a. Involves a joint. b. Involves the face, hands, or feet. c. Is infected. d. Requires more than 2 weeks for healing. e. Involves very large surface areas

ANS: A, B, D Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization. Grafting is not done while a burn is infected. There may not be enough healthy skin to graft large areas. DIF: Cognitive Level: Comprehension OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

14. The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower than normal ratio may indicate acquired immunodeficiency syndrome (AIDS). What is the role of T4 cells? a. Enhances humoral immune response. b. Suppresses the humoral response. c. Suppresses the cell-mediated response. d. They are a feature of an autoimmune disease.

ANS: A Once contact is made with a specific antigen, the T lymphocyte differentiates into helper/inducer T cells, suppressor T cells, and cytotoxic killer cells. Although these T cells are microscopically identical, they can be distinguished by proteins present on the cell surface called cluster of differentiation (CD). Helper T cells (also known as T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cell-mediated responses. The ratio of helper to suppressor T cells is normally 2:1, and an alteration in this ratio may cause disease. For example, a depressed ratio (a decrease of helper T cells in relation to suppressor T cells) is found in acquired immunodeficiency syndrome (AIDS), whereas a higher ratio (a decrease in suppressor T cells in relation to helper T cells) is a feature of an autoimmune disease. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Step: Assessment MSC: NCLEX: Physiological Integrity

23. A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible non-burn injured skin disorder? a. Toxic epidermal necrolysis b. Staphylococcal scalded skin syndrome c. Necrotizing soft tissue infection d. Graft versus host disease

ANS: A Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present with acute onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours, skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury. Staphylococcal scalded skin syndrome presents predominantly in children. Necrotizing soft tissue infection results from rapidly invasive bacterial infections. Graft versus host disease is not logical given the clinical information provided. DIF: Cognitive Level: Comprehension OBJ: Review the anatomy and physiology of the integumentary system. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

5. The nurse examines the patient's complete blood count with differential analysis and notices that the patient's neutrophils are elevated, but the lymphocytes are lower than normal. What is the drop in lymphocyte count in the differential most likely due to? a. The increase in neutrophil count. b. A new viral infection. c. A decreased number of "bands." d. The lack of immature neutrophils.

ANS: A The differential count measures the percentage of each type of white blood cell (WBC) present in the venous blood sample, the total adding up to 100%. If the percentage of one type of WBC goes up (neutrophil count), the percentage of the remaining WBCs must go down as a result of the mathematical function of the differential. An elevation in the neutrophil count usually indicates a bacterial infection. "Bands" are immature neutrophils. The phrase "a shift to the left" refers to an increased number of "bands," or band neutrophils, compared with mature neutrophils on a complete blood count (CBC) report. This finding generally indicates an acute bacterial infectious process (not viral) that draws on the WBC reserves in the bone marrow and causes less mature forms to be released. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

7. Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered c. Administration of potassium as ordered d. Administration of calcium as ordered e. Prevention of infection

ANS: A, B, D Ineffective coagulation is a serious complication for a trauma patient that can be prevented by maintaining normothermia, evaluating and treating for hypocalcemia, administering clotting factors found in fresh frozen plasma or platelets, and evaluating and treating metabolic acidosis. Evaluating and treating serum potassium levels is important for effective cardiac muscle function, not coagulation. Infection prevention is important as a general intervention related to effective nursing care. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Assessment | Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity

31. The patient admitted with neutropenia, should have regular assessments focus on what? a. Identifying signs of systemic infection. b. Monitoring for a drop in temperature from its normal set point. c. The absence of chills. d. Presence of bradycardia.

ANS: A There are no specific signs or symptoms of a low neutrophil count. Every body system is examined for physical findings of infection. Typical signs may not be evident. Pain such as sore throat or urethral discomfort may be indicative of an infected site. Areas of heavy bacterial colonization (e.g., oral mucosa, perineal area, and venipuncture and catheter sites) have the highest risk of infection; however, the most common clinical infections are sepsis and pneumonia. Additional signs or symptoms of systemic infection include a rise in temperature from its normal set point, chills, and accompanying tachycardia. DIF: Cognitive Level: Application OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also due to the patients' long-term management. Which of the following statements apply to trauma patients? (Select all that apply.) a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection. e. Early ambulation is critical to achieving desired outcomes

ANS: A, B, C Prevention of infection is essential in the care of trauma and postsurgical patients. Removing invasive devices when they are no longer needed for monitoring and ensuring aseptic care of devices are important nursing care considerations for management of indwelling urinary catheters, central lines, and airway adjuncts. Wounds, other than the immediate postoperative dressing, are not required to be sterile. Aseptic technique is used for wound care. While ambulation is important to general recovery, early ambulation may not be practical or even desirable. DIF: Cognitive Level: Comprehension OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

1. Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration. e. Oral medication is the preferred administration route

ANS: A, B, C The rapid metabolism associated with burn injury may require additional pain medication. Many of the procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication should be given prior to the procedures. Edema in burned patients alters the absorption of medications that are injected intramuscularly; therefore, drugs must be administered by the IV route. DIF: Cognitive Level: Application OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

3. The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which intervention? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages e. Administering muscle relaxants around the clock

ANS: A, B, D It is important to avoid immobility in patients with burns of the hands, feet, or major joints. Measures must be taken to maintain the function of the hands, feet, and major joints. Nursing interventions to maintain range of motion, applying splits to keep the extremities in a position of function, and individually wrapping fingers and toes are necessary to maintain function of the hands, feet, and joints. Effective pain management is necessary to encourage mobility. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

6. Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event? (Select all that apply.) a. Establish a family spokesperson. b. Ask the family about their normal coping mechanisms. c. Limit visitation to set times throughout the day. d. Coordinate a family conference. e. Provide an effective communication system between staff and family

ANS: A, B, D, E The trauma team can assist the patient and family in crisis by helping them establish a consistent communication process between the healthcare team and family. Other interventions include exploring the family's perceptions of the event, support systems, and coping mechanisms. Family conferences early in the emergent phase and frequently during the critical care phase assist with communication and with understanding the patient's and family's expectations for care. Limiting visitation will not assist the patient or the family's ability to cope with the traumatic event. DIF: Cognitive Level: Analysis OBJ: Describe assessment and management of common traumatic injuries. TOP: Nursing Process Step: Assessment | Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

5. Which complication may manifest after an electrical injury? (Select all that apply.) a. Long bone fractures b. Cardiac dysrhythmias c. Hypertension d. Compartment syndrome of extremities e. Dark brown urine f. Peptic ulcer disease g. Acute cataract formation h. Seizures

ANS: A, B, D, E, G, H Electrical injuries vary in severity of injury by the intensity of energy exposed to the body. Manifestations and complications may include cardiac dysrhythmias or cardiopulmonary arrest, hypoxia, deep tissue necrosis, rhabdomyolysis and acute kidney injury, compartment syndrome, long bone fractures, acute cataract formation, and neurological deficits (including seizures). Hypertension and peptic ulcer disease are not direct consequences of electrical burn injuries. DIF: Cognitive Level: Application OBJ: Compare types of burn injuries. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

8. Which of the following findings require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury? (Select all that apply.) a. Mean arterial pressure 48 mm Hg b. Elevated serum blood alcohol level c. Non-reactive pupils d. Respiratory rate of 10 breaths per minute e. History of posttraumatic stress disorder (PTSD)

ANS: A, C, D Rapid assessment of patients with neurological injury is vital to the treatment of patients with traumatic brain injury. Preventing hypotension (mean arterial pressure less than 50 mm Hg) is essential to maintain cerebral perfusion; non-reactive pupils are an abnormal finding and require immediate attention to evaluate the cause. Adequate oxygenation and ventilation are necessary to deliver oxygen to the brain; thus, a respiratory rate of 10 requires further evaluation. An elevated blood alcohol level interferes with the ability to conduct a neurological examination but does not require immediate intervention. While posttraumatic stress disorder will need to be addressed, it does not require priority as does the identified abnormal physical findings. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air e. Fractured ribs

ANS: A, C, D, E Pulmonary contusion is a serious injury associated with deceleration or blast forces and is a common cause of death after chest trauma. The clinical presentation includes chest wall abrasions, ecchymosis, bloody secretions, and a partial pressure of arterial oxygen (PaO2) of less than 60 mm Hg while breathing room air. The bruised lung tissue becomes edematous, resulting in hypoxia and respiratory distress. A fractured rib could trigger the bruising of lung tissue. Absence of breath sounds is more suggestive of atelectasis or a collapsed lung. DIF: Cognitive Level: Analysis OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a. Crush injury to right arm b. Gunshot wound to the abdomen c. Lightning strike of the left arm and chest d. Pulmonary contusion and rib fracture e. Second degree burns to 40% of the body

ANS: A, C, E Causes of rhabdomyolysis include crush injuries, compartment syndrome, burns, and injuries from being struck by lightning. Acute kidney injury may result from a gunshot wound related to prolonged hypotension. Acute kidney injury would not have a direct cause associated with a pulmonary contusion. DIF: Cognitive Level: Analysis OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

4. Which infection control strategy should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management.

ANS: A, C, E Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and restricting family is not an intervention related to infection prevention. DIF: Cognitive Level: Application OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

17. What is the most likely site to have a sheet graft applied? a. Arm b. Face c. Leg d. Chest

ANS: B A sheet graft is more likely to be used on the face and hands because the cosmetic effects are more optimal. Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg, chest, etc.). DIF: Cognitive Level: Comprehension OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

7. A patient admitted with severe burns to the face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to what data noted in the patient's medical history? a. Excessive alcohol use b. Methamphetamine use c. Posttraumatic stress disorder d. Subacute delirium

ANS: B A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury. DIF: Cognitive Level: Application OBJ: Compare types of burns. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

10. What is the process by which the body actively produces cells and mediators that result in the destruction of the antigen? a. Passive immunity b. Active immunity c. Autoimmunity d. Recognition of self as nonself

ANS: B Active immunity is a term used when the body actively produces cells and mediators that result in the destruction of the antigen. Passive immunity is that which is transferred from another person (e.g., maternal antibodies transferred to the newborn through the placenta). In autoimmunity, the body abnormally sees self as nonself and an immune response is activated against those tissues. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

38. The nurse assessing a patient being admitted for anemia observes no overt signs of bleeding. The nurse understands what fact about the clinical presentation of anemia? a. All patients with bleeding disorders demonstrate active bleeding. b. Many patients have bleeding that is not obvious. c. Mucous membranes have a high threshold for bleeding. d. Capillaries in mucous membranes lie deep in the membrane.

ANS: B Although many patients with bleeding disorders demonstrate active bleeding from body orifices, mucous membranes, and open lesions or intravenous line sites, equal numbers of patients have less obvious bleeding. The most susceptible sites for bleeding are existing openings in the epithelial surfaces. Mucous membranes have a low threshold for bleeding because the capillaries lie close to the membrane surface, and minor injury may damage and expose vessels. Substantial blood loss can occur in any coagulopathy, resulting in hypovolemic shock. DIF: Cognitive Level: Comprehension OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

7. When examining the patient's laboratory values, the nurse notices an elevation in the eosinophil count. The nurse realizes that eosinophils become elevated when what occurs? a. An acute bacterial infection b. A response to allergens and parasites. c. When the spleen is removed. d. Situations that do not require phagocytosis.

ANS: B An elevation in the neutrophil count (not eosinophil count) usually indicates a bacterial infection. Eosinophils are important in the defense against allergens and parasites and are thought to be involved in the detoxification of foreign proteins. Eosinophils are found largely in the tissues of the skin, lung, and gastrointestinal tract (not the spleen). Eosinophils respond to chemotactic mechanisms triggering them to participate in phagocytosis. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Step: Assessment MSC: NCLEX: Physiological Integrity

25. The nurse is assessing a patient being admitted with reports of fatigue and shortness of breath as well as abdominal tenderness. The nurse notes that the patient is jaundiced; the physical examination reports an enlarged liver. These assessment findings support what possible blood related disorder? a. Aplastic anemia b. Hemolytic anemia c. Sickle cell anemia d. Anemia due to acute blood loss

ANS: B Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or liver. These findings result from the increased destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation of breakdown products. The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development. Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis). DIF: Cognitive Level: Analysis OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. Of the four major blood components, what statement is true about plasma? a. It is made up of circulating ions. b. It comprises about 55% of blood volume. c. It is transported to the cells by serum proteins. d. It comprises about 45% of blood volume.

ANS: B Blood has four major components: (1) a fluid component called plasma, (2) circulating solutes such as ions, (3) serum proteins, and (4) cells. Plasma comprises about 55% of blood volume and is the transportation medium for important serum proteins such as albumin, globulin, fibrinogen, prothrombin, and plasminogen. The hematopoietic cells comprise the remaining 45% of blood volume. DIF: Cognitive Level: Comprehension OBJ: Explain the normal anatomy and physiology of the hematological and immune systems. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

20. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for what possible mental health condition? a. Acute delirium b. Posttraumatic stress disorder c. Suicidal intentions d. Bipolar disorder

ANS: B Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients th at demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder. Acute delirium is more likely to occur during the acute phase of injury. Suicidal ideations should always be addressed if the patient expresses or shows signs of suicidal thoughts. Burn-injured patients may have an underlying mental health disorder that requires treatment, such as bipolar disorder or schizophrenia. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

18. The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. What is a primary nursing diagnosis for this patient? a. Altered nutrition, less than body requirements b. Body image disturbance c. Decreased cardiac output d. Fluid volume deficit

ANS: B Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result. Nutritional support is started early in management of the patient with burns, and there is no indication that this patient has a nutritional deficit. Nursing care plan priorities would also continue to focus on nutritional needs to optimize healing. Decreased cardiac output and fluid volume deficit should not be priority concerns during the wound closure phase of burn wound management by grafting. DIF: Cognitive Level: Application OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

13. What mediates cellular immunity? a. B lymphocytes b. T lymphocytes c. Immunoglobulins d. Suppressor B cells

ANS: B Cellular immunity is mediated by the T lymphocyte. Humoral immunity is mediated by B lymphocytes and involves the formation of antibodies (immunoglobulins) in response to specific antigens that bind to their receptor sites. Suppressor T cells (not B cells) downgrade and suppress the humoral and cell-mediated responses. DIF: Cognitive Level: Knowledge OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

12. An elderly individual from an assisted living facility (ALF) presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do to best achieve an accurate history of the event? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patient's burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred.

ANS: B In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver. While obtaining safety information on the temperature of the water heater is important, it is not a priority assessment question. The nurse should follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may include contacting the police or social services. Asking the caregiver to describe how the injury occurred is important (e.g., there may be discrepancies in the physical assessment and reported mechanism of burn injury); however, examining the patient away from the caregiver is a priority. DIF: Cognitive Level: Application OBJ: Compare types of burn injuries. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

19. The nurse is assisting the patient who is recovering from moderate burns to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals? a. "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal." b. "Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal." c. "It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster." d. "Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing."

ANS: B Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

10. When paramedics report singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a. Carbon monoxide poisoning always occurs when soot is visible. b. Inhalation injury above the glottis may cause significant edema that obstructs the airway. c. The patient will have a copious amount of mucus that will need to be suctioned. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

ANS: B In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation. DIF: Cognitive Level: Comprehension OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

9. What is true about lymphocytic B cells? a. They mature in lymphoid tissue. b. They mediate humoral immunity. c. They migrate to the thymus gland. d. They destroy virus-infected cells.

ANS: B Lymphocytes are responsible for specific immune responses and participate in two types of immunity: humoral immunity, which is mediated by B lymphocytes; and cellular immunity, which is mediated by T lymphocytes. B lymphocytes, or B cells, originate in the bone marrow and are also thought to mature there. B cells perform in antibody production. T cells are produced in the bone marrow, but they migrate to the thymus for maturation; then, most of them travel and reside in lymphoid tissues throughout the body. They live longer than B cells and participate in long-term immunity. The natural killer cell is a third type of lymphocyte, thought to be a differentiated form of the T lymphocyte. It is responsible for surveillance and destruction of virus-infected and malignant cells. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

29. The nurse is evaluating the patient's laboratory values and notes an IgG level of 240 mg/dL. The nurse realizes that this patient is a candidate for what care intervention? a. Continuation of current therapy b. An immunoglobulin infusion c. Gene replacement therapy d. Increased doses of immunosuppressive medications

ANS: B Medical therapy is directed at reversing the cause of the immune dysfunction and preventing infectious complications. In primary immunodeficiencies, B-cell and T-cell defects are treated with specific replacement therapy or bone marrow transplantation. IgG blood levels of less than 300 mg/dL warrant immunoglobulin infusion. Gene replacement therapy may soon be a realistic curative treatment option for some disorders. In secondary immunodeficiencies, the underlying causative condition is treated. For example, malnutrition is corrected, or doses of immunosuppressive medications are adjusted. For this patient, immunosuppressive medications should be discontinued or doses lowered. DIF: Cognitive Level: Analysis OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

8. What term is used to identify monocytes found in the liver? a. Alveolar macrophages b. Kupffer's cells c. Histiocytes d. Monokines

ANS: B Monocytes are the largest of the leukocytes and constitute only 3% to 7% of the WBC differential. Once they migrate from the bloodstream into the tissues, monocytes mature into tissue macrophages, which are powerful phagocytes. In the lung, these tissue macrophages are known as alveolar macrophages; in the liver, they are Kupffer's cells; in connective tissue, they are histiocytes. When activated by antigens, macrophages secrete substances called monokines that act as chemical communicators between the cells involved in the immune response. DIF: Cognitive Level: Knowledge OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Step: Assessment MSC: NCLEX: Physiological Integrity

14. The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to accomplish what outcome? a. Maintain a closed wound system to decrease the risk of infection. b. Remove excessive wound fluid and promote moist wound healing. c. Increase patient mobility with large burn wounds. d. Quantify wound drainage amount for more accurate output assessment.

ANS: B Negative-pressure wound therapy can be used to treat grafts or partial-thickness burns by decompressing edematous interstitial spaces that enhance local perfusion, optimizing wound healing. This therapy also provides a moist wound-healing environment. The system is closed and may reduce the risk of infection but may not prevent infection. Patients are less mobile because the system needs an electrical source to function. Wound drainage is quantified by using the negative-pressure wound therapy system, but this is not a primary indication for the therapy. DIF: Cognitive Level: Comprehension OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

13. During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent what potential complication? a. Disseminated intravascular coagulation b. Multisystem organ dysfunction c. Septic shock d. Wound infection

ANS: B Patients with multisystem injuries are at high risk of developing myriad complications associated with the overwhelming stressors of the injury, prolonged immobility, and consequences of inadequate tissue perfusion and oxygenation. Maintaining effective tissue perfusion, oxygenation, and nutritional support are all vital to prevent progression into multiple organ dysfunction syndrome. Disseminated intravascular coagulation, septic shock, and wound infections are best prevented by addressing infection early and aggressively with appropriate antibiotics and nursing interventions to reduce infection (e.g. hand hygiene). DIF: Cognitive Level: Understand OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. When providing information on trauma prevention, it is important to realize that individuals age 25 to 44 years are most likely to experience which type of trauma incident? a. High-speed motor vehicle crashes b. Poisonings from prescription or illegal drugs c. Violent or domestic traumatic altercations d. Work-related falls

ANS: B People age 25 to 44 years are at greater risk of experiencing poisonings from prescription and/or illegal drugs resulting in unintentional injury, followed by motor vehicle crashes (MVCs). MVCs and homicide are the leading causes of death for individuals age 16 to 24 years, and falls are responsible for traumatic injuries in the 65 years and older population. Domestic violence is not well defined as an age-related trauma incident. DIF: Cognitive Level: Comprehension OBJ: Identify mechanisms of traumatic injury commonly seen in the critical care setting. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

14. Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent this common complication observed in trauma patients? a. Catheter-associated infection b. Venous thromboembolism c. Fat embolism d. Nosocomial pneumonia

ANS: B Prevention of venous thromboembolism is essential in the management of trauma patients. If not medically contraindicated, patients should receive pharmacological prophylaxis (e.g. heparin or heparin derivatives). Nurses should encourage ambulation, evaluate the patient's overall hydration, and ensure sequential compression devices are used properly. Prevention of catheter-associated infections is also important through interventions that maintain the integrity of the catheter site and injection ports. Hydration and ambulation, along with pulmonary exercises, help prevent pneumonia. Fat embolism is associated with long bone fractures and early recognition of this complication is essential to treatment. DIF: Cognitive Level: Understand OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

13. Why is silver is used as an ingredient in many burn dressings? a. Stimulates tissue granulation. b. Is effective against a wide spectrum of wound pathogens. c. Provides topical pain relief. d. Stimulates wound healing.

ANS: B Silver is an ingredient in many dressings because it helps prevent infection against a wide spectrum of common pathogens. Silver does not stimulate tissue granulation; nor does it provide pain relief or stimulate wound healing processes. DIF: Cognitive Level: Comprehension OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. In patients with extensive burns, what process is responsible for edema occurring in both burned and unburned areas? a. Catecholamine-induced vasoconstriction b. Decreased glomerular filtration c. Increased capillary permeability d. Loss of integument barrier

ANS: C Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third spacing). Catecholamine-induced vasoconstriction does not produce edema. Decreased glomerular filtration may cause fluid retention, but it is not responsible for the extensive edema seen after burn injury. Loss of integument barrier does not cause edema. DIF: Cognitive Level: Comprehension OBJ: Describe the pathophysiology of burns. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

5. The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? What is the priority intervention in the plan of care? a. Keeping the extremity in a dependent position b. Active and passive range of motion every hour c. Preparing for an escharotomy as a prophylactic measure d. Splinting the forearm

ANS: B Special attention is given to circumferential (completely surrounding a body part) full thickness burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema. Peripheral pulses are assessed every hour, especially in circumferential burns of the extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome are present on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

17. In vivo, the primary activator of the coagulation cascade occurs via what pathway? a. Intrinsic b. Extrinsic c. Common d. Either intrinsic or extrinsic

ANS: B The classic theory of coagulation is viewed as occurring through two distinct pathways, intrinsic and extrinsic, which share a common "final" pathway, formation of insoluble fibrin. It is now known that the classic cascade theory of coagulation illustrates what occurs in vitro. In vivo, the primary activator of the coagulation cascade occurs via the extrinsic pathway. The intrinsic pathway serves to amplify the coagulation cascade. DIF: Cognitive Level: Knowledge OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Step: Assessment MSC: NCLEX: Physiological Integrity

4. Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a. A fall from a 6-foot ladder onto the grass b. A shotgun wound to the abdomen c. A knife wound to the right chest d. A motor vehicle crash in which the driver hits the steering wheel

ANS: B The penetrating injury of the gunshot wound would cause the greatest amount of injury because of the kinetic energy and dispersion pattern of the shotgun ammunition once it penetrated the body. A fall would cause a compression injury from the blunt force of the fall. The knife wound would cause a penetrating injury in which the magnitude of the injury would depend on damage to the vessels and lung. Blunt chest trauma that may include a cardiac contusion is possible following an injury in which the patient hits the steering column. DIF: Cognitive Level: Analysis OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

23. What term is used to identify a reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues? a. Polycythemia b. Anemia c. Iron deficiency d. An increase in hemoglobin

ANS: B The term anemia refers to a reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues. Polycythemia, a disorder in which the number of circulating RBCs is increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive pulmonary disease). Iron deficiency anemia is the most common type of anemia. DIF: Cognitive Level: Knowledge OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

24. What type of burn is capable of producing either a superficial cutaneous injury or a cardiopulmonary arrest and transient but severe central nervous system deficits? a. Chemical burn b. Electrical burn c. Heat burn d. Infection

ANS: B Tissue damage results from the conversion of electrical energy into heat. Monitor the patient for cardiac dysrhythmias. DIF: Cognitive Level: Comprehension OBJ: Describe the pathophysiology of burns. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

36. The patient is admitted with multiple myeloma. The nurse should be prepared to address which related problem? a. Fever b. Night sweats c. Bone pain d. Lymph node enlargement

ANS: C Bone pain is common in multiple myeloma, whereas lymph node enlargement is more representative of lymphoma. Fever is particularly difficult to interpret because it may be a manifestation of the disease process or may accompany an infectious complication. General signs and symptoms such as fatigue, malaise, myalgias, activity intolerance, and night sweats are nonspecific indicators of immune disease. DIF: Cognitive Level: Comprehension OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

17. Which statement about mass casualty triage during a disaster is true? a. Priority treatments and interventions focus primarily on young victims. b. Disaster victims with the greatest chances for survival receive priority for treatment. c. Once interventions have been initiated, healthcare providers cannot stop the treatment of disaster victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.

ANS: B Victims are triaged based on the severity of injury. Patients receive treatment based on the assessment of greatest chances for survival matched to resources available for medical intervention. Age is not a determination in rendering interventions. Patient survival and severity of injury are the priority assessment for triage. If interventions are initiated and found to be ineffective, treatment can be stopped according to principles of ethical care. Color-coded systems are frequently used during disasters to signify patients in greatest need of assistance, with red indicating worse severity of injury and green being most stable. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment OBJ: Describe a system approach to trauma care. MSC: NCLEX: Safe and Effective Care Environment Copyright © 2021, Elsevier Inc. All Rights Reserved.

40. The patient admitted with anemia caused by blood loss and thrombocytopenia has a platelet count of 22,000/microliter. The patient is scheduled for a transfusion of red blood cells (RBCs) and a transfusion of platelets. The nurse should take what action? a. Give the RBCs before the platelets. b. Give the platelets before the RBCs. c. Use local therapies to stop the bleeding. d. Give the platelets and RBCs at the same time.

ANS: B When the patient's blood does not clot because of thrombocytopenia, administration of RBCs before platelets will result in RBC loss from disrupted vascular structures. Platelets should be given first. Local therapies to stop bleeding are used when systemic anticoagulation is necessary for treatment of another health condition (e.g., myocardial infarction, ischemic stroke, or pulmonary embolism). Local procoagulants act by direct tissue contact and initiation of a surface clot. DIF: Cognitive Level: Application OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. Step: Implementation MSC: NCLEX: Physiological Integrity TOP: Nursing Process

4. It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. Acute respiratory distress syndrome (ARDS) b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction e. Reduced tissue perfusion

ANS: B, C, D, E Prolonged hypothermia is associated with the development of myocardial dysfunction, coagulopathies, reduced perfusion, and dysrhythmias (bradycardia and atrial or ventricular fibrillation). ARDS is a complication associated with excessive inflammation and over-resuscitation. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

1. Fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully cross-matched blood products are administered. e. Type O blood can be administered in emergency situations.

ANS: B, C, E Lactated Ringer's and normal saline are the crystalloids of choice in trauma resuscitation. Because hypothermia is a concern, fluids should be warmed. Massive blood transfusions are associated with poor outcomes. Cross-matched blood is preferred, but blood type O, universal donor blood, can be administered in an emergency. DIF: Cognitive Level: Comprehension OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) a. Burn injury less than 10% b. Bedrest c. Burns to lower extremities d. Electrical burn injury e. Delayed fluid resuscitation

ANS: B, C, E Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bedrest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. A patient who weighs 154 pounds has a burn injury that covers 50% of body surface area. The nurse calculates the intravenous (IV) fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula. The nurse plans to administer what amount of fluid in the first 24 hours? a. 2800 mL b. 7000 mL c. 14 L d. 28 L

ANS: C 154 pounds/2.2 = 70 kg 4 × 70 kg × 50 = 14,000 mL, or 14 liters. DIF: Cognitive Level: Analysis OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

41. The patient has a platelet count of 9,000/microliter. The nurse is correct to assume what? a. This is a normal platelet level. b. Spontaneous bleeding may occur. c. The patient is at great risk for fatal hemorrhage. d. This level is considered slightly low.

ANS: C A quantitative deficiency of platelets is termed thrombocytopenia. By definition, this is a platelet count of less than 150,000/microliter. A value of 30,000/microliter is considered critically low, and spontaneous bleeding may occur. Fatal hemorrhage is a great risk when the count is less than 10,000/microliter. DIF: Cognitive Level: Comprehension OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. What is the optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment? a. Blood urea nitrogen b. Daily weight c. Hourly intake and urine output d. Serum potassium

ANS: C During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone. Blood urea nitrogen may be used to monitor volume status, but it is affected by the hypermetabolic state seen after burns, so it is not the optimal measure of intravascular fluid status. Daily weight measures overall volume status, not just intravascular volume. Serum potassium is released with tissue damage and thus is not the optimum measure of intravascular fluid status. DIF: Cognitive Level: Comprehension OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

11. Which patient has the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a. A patient who has a closed head injury with a decreased level of consciousness b. A patient who has a fractured femur and is currently in traction c. A patient who has received large volumes of fluid and/or blood replacement d. A patient who has underlying chronic obstructive pulmonary disease

ANS: C During states of hypoperfusion and acidosis, inflammation occurs and vessels become more permeable to fluid and molecules. With aggressive fluid resuscitation, this change in permeability allows the movement of fluid from the intravascular space into the interstitial spaces (third spacing). As more IV fluids are given to support systemic circulation, fluids continue to migrate into the interstitial space, causing excessive edema and predisposing the patient to additional complications such as abdominal compartment syndrome, ARDS, acute kidney injury, and MODS. A patient with a closed head injury, a patient with a fractured femur stabilized by traction, and a patient with chronic obstructive pulmonary disease may develop ARDS, but it would be related to fluid resuscitation and excessive inflammation associated with traumatic injury. DIF: Cognitive Level: Analysis OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen-carrying molecule referred to by what term? a. Erythropoietin b. A reticulocyte c. Hemoglobin d. 2,3-DPG

ANS: C Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen-carrying molecule called hemoglobin. RBCs are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Erythropoietin is secreted by the kidney in response to a perceived decrease in perfusion or tissue hypoxia. Reticulocytes are immature RBCs that may be released when there is a demand for RBCs that exceeds the number of available mature cells. The oxygen affinity for hemoglobin is modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG) and depends on the blood pH and body temperature. DIF: Cognitive Level: Knowledge OBJ: Explain the normal anatomy and physiology of the hematological and immune systems. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

8. In the trauma patient, what is the most common cause of symptoms of decreased cardiac output? a. Cardiac contusion b. Cardiogenic shock c. Hypovolemia d. Pericardial tamponade

ANS: C Hypovolemia is commonly associated with traumatic injury resulting from acute blood loss. Cardiac contusion may decrease cardiac output, but hypovolemia occurs more often. Cardiogenic shock is not typically associated with trauma. Pericardial tamponade would decrease cardiac output but is not as common as hypovolemia. DIF: Cognitive Level: Understand OBJ: Describe assessment and management of common traumatic injuries. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

28. Critical to caring for the immunocompromised patient is the understanding what fact? a. The immunocompromised patient has normal white blood cell (WBC) physiology. b. The immunosuppression involves a single element or process. c. Infection is the leading cause of death in these patients. d. Immune incompetence is symptomatic even without pathogen exposure.

ANS: C Infection is the leading cause of death in the immunocompromised patient. The immunocompromised patient is one with defined quantitative or qualitative defects in WBCs or immune physiology. The defect may be congenital or acquired, and may involve a single element or multiple processes. Regardless of the cause, the physiological outcome is immune incompetence, with lack of normal inflammatory, phagocytic, antibody, or cytokine responses. Immune incompetence is often asymptomatic until pathogenic organisms invade the body and create infection. DIF: Cognitive Level: Comprehension OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

11. A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for what complication? a. Acute kidney injury b. Acute respiratory distress syndrome c. Intraabdominal hypertension d. Disseminated intravascular coagulation disorder

ANS: C Intraabdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function. Acute kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen. Disseminated intravascular disorder may present as a tense abdomen if there is active bleeding, but it would not present with pulmonary symptoms. DIF: Cognitive Level: Comprehension OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

35. The patient diagnosed with lymphoma has a normal white blood cell (WBC) count. The nurse expects this to result in what patient related characteristic? a. Normal WBC function b. Increased bruising and bleeding. c. An increased risk for infection. d. A risk for developing an allergic reaction.

ANS: C Malignant diseases involving WBCs are termed leukemia, lymphoma, and plasma cell neoplasm (multiple myeloma). Regardless of the specific neoplastic disorder, a deficiency of functional WBCs is a common problem. Despite normal serum cell counts, WBC activity is always impaired, and infection is the most common complication of all these disorders. DIF: Cognitive Level: Analysis OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. Which statement best defines the term traumatic injury? a. All trauma patients can be successfully rehabilitated. b. Traumatic injuries cause more deaths than heart disease and cancer. c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d. Trauma mainly affects the older adult population.

ANS: C Many patients who sustain traumatic injury are under the influence of alcohol, drugs, or other substances. Rehabilitation potential depends on multiple factors including severity of injury, patient age, and comorbidities. Heart disease and cancer claim more lives than trauma, but trauma claims lives of predominantly young individuals. DIF: Cognitive Level: Comprehension OBJ: Identify mechanisms of traumatic injury commonly seen in the critical care setting. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

22. The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a. "Do you live alone?" b. "Do you have any drug or food allergies?" c. "Do you have a heart condition or heart failure?" d. "Have you had any surgeries?"

ANS: C Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutrition status, and comorbid diseases, especially heart failure. Assessment questions should include, as a priority, information about the patient's cardiovascular status, including heart failure. Obtaining food or drug allergy information is also important along with other past medical history, including past surgeries. Information on the patient's living arrangements is an important safety consideration for discharge planning. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6. The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient, 22 years old and smelling of alcohol, begins to vomit. Which intervention is most appropriate? a. Insert an oral airway to prevent aspiration and to protect the airway. b. Offer the patient an emesis basin so that you can measure the amount of emesis. c. Prepare to suction the oropharynx while maintaining cervical spine immobilization. d. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

ANS: C Stabilization of the cervical spine, preventing aspiration, and maintaining a patent airway are essential elements of trauma management. An oral airway may increase the risk of aspiration related to the emesis and offering an emesis basin would contradict spine precautions. Alcohol level is best determined by serum analysis. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

6. The patient asks the nurse if the placement of the autograft over a full-thickness burn will be the only surgical intervention needed to close the wound. What is the nurse's best response? a. "Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound." b. "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." c. "Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." d. "Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound."

ANS: C The autograft is the only permanent method of grafting and it uses the patient's own tissue to cover the burn wound. Autografting is permanent and does not require a second surgery unless the graft fails. A biological or biosynthetic graft or dressing is a temporary wound covering. A xenograft is from an animal, usually pig skin and is a temporary graft. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

20. A patient with a history of pulmonary embolism is being worked up for a potential coagulopathy that increases the risk for clotting. The nurse understands that the provider may order a test related to identifying what deficiency? a. Factor VII deficiency b. Factor X deficiency c. Protein C deficiency d. Factor IX deficiency

ANS: C The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the liver. Vitamin K is necessary for synthesis of factors II, VII, IX, X, necessary for clotting to occur and for anticoagulation factors protein C and protein S. A deficiency of anticoagulation factors could lead to increased clot formation and problems such as stroke and pulmonary emboli. DIF: Cognitive Level: Analysis OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Step: Assessment MSC: NCLEX: Physiological Integrity

32. The patient's white blood cell (WBC) level is 4000 cells/microliter. The differential shows a neutrophil count of 65% and a band level of 5%. What is the patient's absolute neutrophil count? a. 4000 cells/microliter b. 3000 cells/microliter c. 2800 cells/microliter d. 2600 cells/microliter

ANS: C The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute neutrophil count is calculated by multiplying the total WBC count (without a decimal point) by the percentages (with decimal points) of polymorphonuclear leukocytes (polys; also called segs or neutrophils) and bands (immature neutrophils). WBC × (segs + bands) This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia. DIF: Cognitive Level: Application OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

22. The patient is being seen for reports of general malaise, fatigue, and shortness of breath. The patient states these symptoms started with a cold 6 weeks earlier. The nurse should expect the provider to order what diagnostic test? a. Lymph node biopsy b. Differential blood count only c. Complete blood count (CBC) with differential d. Bone marrow biopsy

ANS: C The first screening diagnostic tests performed to detect hematological or immunological dysfunction are a Complete Blood Count (CBC) with differential and a coagulation profile. The CBC evaluates the cellular components of blood. The CBC reports the total RBC count and RBC indices, hematocrit, hemoglobin, WBC count and differential, platelet count, and cell morphologies. The most invasive microscopic examinations of the bone marrow or lymph nodes are reserved for circumstances when laboratory tests are inconclusive or when an abnormality in cellular maturation is suspected (e.g., aplastic anemia, leukemia, or lymphoma). A differential laboratory test is not done without the CBC first. A bone marrow biopsy is not warranted; it would only be done if preliminary studies indicated a hematological problem. DIF: Cognitive Level: Analysis OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for what complication? a. Acute kidney injury b. Acute respiratory distress syndrome c. Infection d. Stress ulcers

ANS: C The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection. A systemic inflammatory response (SIRS) also increases the risk of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of stress ulcers. DIF: Cognitive Level: Comprehension OBJ: Describe the pathophysiology of burns. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

5. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. What should the primary survey of this patient upon arrival to the ED include? a. A cervical spine x-ray study to determine the presence of a fracture. b. Turning the patient from side to side to get a look at his back. c. Getting a baseline assessment and establish priorities. d. A methodical head-to-toe assessment identifying injuries and treatment priorities.

ANS: C The primary survey is a systematic rapid assessment of the patient's airway with cervical spine immobilization, breathing and ventilation, circulation with hemorrhage control, disability or neurological status, and exposure/environmental considerations. The secondary survey is more methodical and involves identifying injuries and specific treatment priorities. DIF: Cognitive Level: Application OBJ: Describe assessment and management of common traumatic injuries. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6. The nurse is caring for a patient receiving chemotherapeutic agents, and notices that the patient's neutrophils count is low. The nurse realizes that as the cause of the neutrophil count? a. The patient has a bacterial infection. b. A shift to the left is occurring. c. Medication has alter the ability to fight infection. d. Neutrophils have a long life span and multiply slowly.

ANS: C The survival time of neutrophils is short. When serious infection is present, neutrophils may live only hours as the neutrophils phagocytize infectious organisms. Because of this short life span, drugs that affect rapidly multiplying cells (e.g., chemotherapeutic agents) quickly decrease the neutrophil count and alter the patient's ability to fight infection. An elevation in the neutrophil count usually indicates a bacterial infection. "Bands" are immature neutrophils. The phrase "a shift to the left" refers to an increased number of "bands," or band neutrophils, compared with mature neutrophils on a complete blood count (CBC) report. DIF: Cognitive Level: Analysis OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

16. Treatment and/or prevention of rhabdomyolysis in at-risk patients include aggressive fluid resuscitation to achieve how much urine output? a. 30 mL/hr b. 50 mL/hr c. 100 mL/hr d. 300 mL/hr

ANS: C Treatment of rhabdomyolysis consists of aggressive fluid resuscitation to flush the myoglobin from the renal tubules. A common protocol includes the titration of IV fluids to achieve a urine output of 100 to 200 mL/hr. Urine volumes less than 100 mL/hr are insufficient and a urine volume greater than 200mL/hr will not harm the patient but may create too aggressive a diuresis. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

4. The nurse is caring for a patient who has undergone a splenectomy, and notices that the patient's platelet count has increased. The nurse realizes that the increase is due to what? a. Platelet response to infection. b. Stimulation secondary to erythropoietin. c. The patient's inability to store platelets. d. The platelet's 120-day life cycle.

ANS: C Two thirds of the platelets circulate in the blood. The spleen stores the remaining third and may become enlarged if excess or rapid platelet removal occurs. In patients who have had a splenectomy, 100% of the platelets remain in circulation. Platelets are the first responders in the clotting response (not infection), and they form a platelet plug that temporarily repairs an injured vessel. RBCs (not platelets) are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Platelets have a life span of 8 to 12 days, but they may be used more rapidly if there are many vascular injuries or clotting stimuli. Maturation of RBCs takes 4 to 5 days, and their life span is about 120 days. DIF: Cognitive Level: Comprehension OBJ: Explain the normal anatomy and physiology of the hematological and immune systems. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

18. What is common to both the intrinsic and the extrinsic pathways? a. Factor XII b. Factor VII c. Factor X d. Subendothelial collagen Nursing Process

ANS: C When blood is exposed to subendothelial collagen or is "injured," factor XII is activated, which initiates coagulation via the intrinsic pathway. In the extrinsic pathway, tissue injury precipitates release of a substance known as tissue factor, which activates factor VII. Factor VII is key in initiating blood coagulation, and the two pathways intersect at the activation of factor X. Both coagulation pathways illustrate a final common pathway of clot formation, retraction, and fibrinolysis. DIF: Cognitive Level: Knowledge OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

16. With minor vessel injury, what statement is true regarding primary hemostasis triggered by a minor vessel injury? a. After the injury occurs, it is takes several minutes to initiate. b. It is achieved with fibrin to solidify the platelet plug. c. It is usually achieved within seconds of the injury d. It is a permanent solution.

ANS: C With minor vessel injury, primary hemostasis is temporarily achieved with platelet plugs, usually within seconds. During secondary hemostasis, the platelet plug is solidified with fibrin, an end product of the coagulation pathway, and requires several minutes to reach completion. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Step: Assessment MSC: NCLEX: Physiological Integrity

15. The nurse understands that immunosurveillance is a function of what cell type? a. Helper T lymphocytes b. Suppressor T lymphocytes c. T4 lymphocyte. d. Killer T lymphocytes

ANS: D Cytotoxic or killer T cells (CD8 marker) participate directly in the destruction of antigens by binding to and altering the intracellular environment, which ultimately destroys the cell. Killer cells also release cytotoxic substances into the antigen cell that cause cell lysis. Killer T cells additionally provide the body with immunosurveillance capabilities that monitor for abnormal cells or tissue. This mechanism is responsible for the rejection of transplanted tissue and the destruction of single malignant cells. Helper T cells (also known as T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cell-mediated responses. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

9. The nurse is providing care to a patient with burns whose care of plan care includes a prescription for opiates to be given intramuscularly for pain. Why would the nurse contact the primary care provider (PCP) to change the order to intravenous administration? a. Intramuscular injections cause additional skin disruption. b. Burn pain is so severe it requires relief by the fastest route available. c. Hypermetabolism limits effectiveness of medications administered intramuscularly. d. Tissue edema may interfere with drug absorption of injectable routes.

ANS: D Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly. Even though it is true intramuscular injections disrupt tissue, medication absorption is not effective. Burn pain is severe and intravenous administration is desired to relieve pain, but this is not the physiological basis for giving medications intravenously. Hypermetabolism affects medication effectiveness but is not the rationale for administering opioids intravenously. DIF: Cognitive Level: Comprehension OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

37. What are cases of primary immunodeficiency usually related to? a. Aging b. Nutritional deficiencies c. Malignancies. d. A single gene defect

ANS: D Most primary immunodeficiencies are congenital disorders related to a single gene defect. Secondary or acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously functional immune defense system. Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as diabetes or sickle cell disease are examples of conditions that may be associated with acquired immunodeficiencies. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

15. The nurse caring for a patient with an electrical injury understands that patients with electrical injury are at a high risk for acute kidney injury secondary to what related process? a. Hypervolemia from burn resuscitation b. Increased incidence of ureteral stones c. Nephrotoxic antibiotics for prevention of infection d. Release of myoglobin from injured tissues

ANS: D Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and acute kidney injury. Hypervolemia is not a cause of acute kidney injury. Ureteral stones and nephrotoxic antibiotics may cause acute kidney injury but is not associated with the electrical injury. DIF: Cognitive Level: Comprehension OBJ: Describe the pathophysiology of burns. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

30. The nurse notes that the patient's neutrophil count is 490 cells/microliter and realizes that this patient has what degree of risk for developing an infection? a. Low risk for infection b. Mild risk for infection c. Moderated risk for infection d. Severe risk for infection

ANS: D Neutropenia is defined as an absolute neutrophil count of less than 1500 cells/microliter of blood. Neutropenia may occur as a result of inadequate production or excess destruction of neutrophils. Patients with low neutrophil counts are predisposed to infections because of the body's reduced phagocytic ability. Neutropenia is classified based on the patient's predicted risk for infection: mild (1000 to 1500 cells/microliter), moderate (500 to 1000 cells/microliter), and severe (<500 cells/microliter). DIF: Cognitive Level: Analysis OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

34. Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count at what level? a. Less than 500 cells/microliter. b. 500 to 1000 cells/microliter. c. 1000 to 1500 cells/microliter. d. 1500 cells/microliter or higher.

ANS: D Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count of 1500 cells/microliter or higher. DIF: Cognitive Level: Comprehension OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

21. The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the primary healthcare provider (PCP) best indicates the nurse's knowledge of pain management for this patient? a. "Can we ask the music therapist to come by each morning to see if that will help the patient's pain?" b. "The patient's pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock." c. "The patient's pain is often unrelieved. It would be best if we can schedule the opioids around the clock." d. "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"

ANS: D Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing independence with pain management strategies. Nonpharmacological pain strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put the control of pain management with the patient. DIF: Cognitive Level: Application OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

12. What is an initial symptom of a suspected compartment syndrome? a. Absence of pulse in affected extremity b. Pallor in the affected area c. Paresthesia in the affected area d. Severe, throbbing pain in the affected area

ANS: D Patients with compartment syndrome complain of increasing throbbing pain disproportionate to the injury. Narcotic administration does not relieve the pain. The pain is localized to the involved compartment and increases with passive muscle stretching. The area affected is firm. Paresthesia distal to the compartment, pulselessness, pallor, and paralysis are late signs and must be reported immediately to prevent loss of the extremity. DIF: Cognitive Level: Understand OBJ: Describe assessment and management of common traumatic injuries. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

26. The patient is reporting severe joint pain as well as fatigue and shortness of breath. The nurse notices that the patient's joints are swollen and edema is noted in both legs. The nurse realizes that these are symptoms support what possible blood related disorder? a. Anemia reflective of low volume b. Aplastic anemia c. Hemolytic anemia d. Sickle cell anemia

ANS: D Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development. In crisis, the sickle cell patient often has decreased urine output, peripheral edema, and signs of uremia because renal tissue perfusion is impaired as a result of sluggish blood flow. Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis). The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or liver. These findings result from the increased destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation of breakdown products. DIF: Cognitive Level: Analysis OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. Erythrocytes (RBCs) are generated from precursor stem cells under the influence of what growth factor? a. Reticulocytes b. Hemoglobin c. 2,3-DPG d. Erythropoietin

ANS: D RBCs are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Erythropoietin is secreted by the kidney in response to a perceived decrease in perfusion or tissue hypoxia. Reticulocytes are immature RBCs that may be released when there is a demand for RBCs that exceeds the number of available mature cells. The RBC transports hemoglobin, whose function is the transport of oxygen and carbon dioxide. Hemoglobin binds with oxygen in the lungs and transports it to the tissues. The oxygen affinity for hemoglobin is modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG) and depends on the blood pH and body temperature. DIF: Cognitive Level: Knowledge OBJ: Explain the normal anatomy and physiology of the hematological and immune systems. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

9. The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels

ANS: D Serum lactate levels are useful in assessing acidosis and the need for aggressive fluid resuscitation. Arterial oxygen saturation provides clinical information on oxygen delivery to cells. Hourly urine output and mean arterial pressure provide information on systemic perfusion and are monitored in the assessment of effective resuscitation; however, serum lactate is a better indicator of metabolic acidosis caused by under-perfusion (under-resuscitation). DIF: Cognitive Level: Comprehension OBJ: Describe assessment and management of common traumatic injuries. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

12. What statement is true regarding humoral immunity and cell-mediated immunity? a. They are mutually exclusive. b. They are non-specific immune responses. c. They are producers of antigens. d. They work together to provide immunity.

ANS: D Specificity refers to the finding that an immune response stimulates cells to develop immunity for a specific antigen. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. They are not mutually exclusive but act together to provide immunity. They do not produce antigens; they produce antibodies. DIF: Cognitive Level: Comprehension OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Step: Assessment MSC: NCLEX: Physiological Integrity

15. Which intervention is a strategy to prevent fat embolism syndrome? a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with low-molecular weight heparin. d. Stabilize extremity fractures early.

ANS: D Stabilization of extremity fractures to minimize both bone movement and the release of fatty products from the bone marrow must be accomplished as early as possible. Administration of statin medications has no effect on prevention of fat embolism. Intubation and mechanical ventilation may be necessary to support the pulmonary system in the event the patient has a fat embolism, but it will not prevent this complication. Heparin will not prevent fat embolism; it is for venous thromboembolism prophylaxis. DIF: Cognitive Level: Analysis OBJ: Formulate a plan of care for the trauma patient, including prevention of complications. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

19. The nurse caring for a patient diagnosed with cirrhosis of the liver notes fresh blood starting to ooze from the patient's rectum and intravenous site. The nurse contacts the provider expecting an order for what intervention? a. Protein S factor b. Blood work to evaluate protein C level. c. A laboratory test to determine factor X level. d. Vitamin K

ANS: D The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the liver. Vitamin K is necessary for synthesis of factors II, VII, IX, X, and protein C and protein S (anticoagulation factors). Thus, liver disease and vitamin K deficiency are commonly associated with impaired hemostasis. DIF: Cognitive Level: Analysis OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

33. The patient has a total white blood cell (WBC) count of 600 cells/microliter. The differential shows a normal neutrophil level of 70% with 5% bands. What is the patient's risk for infection? a. Low b. Mild c. Moderated d. Severe

ANS: D The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute neutrophil count is calculated by multiplying the total WBC count (without a decimal point) by the percentages (with decimal points) of polymorphonuclear leukocytes (polys; also called segs or neutrophils) and bands (immature neutrophils). WBC × (segs + bands) 600 × (0.70 + 0.05) 600 × 0.75 = 450 cells/microliter This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia. Neutropenia is classified based on the patient's predicted risk for infection: mild (1000 to 1500 cells/microliter), moderate (500 to 1000 cells/microliter), and severe (<500 cells/microliter). DIF: Cognitive Level: Analysis OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

10. The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of a car. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates what prescribed intervention? a. Administration of lactated Ringer's solution (1 L) wide open. b. Chest x-ray study to determine the etiology of the symptoms. c. Endotracheal intubation and mechanical ventilation. d. Needle thoracostomy and chest tube insertion.

ANS: D These are classic symptoms of a tension pneumothorax in a patient at high risk related to mechanism of injury. Emergent decompression by a needle thoracostomy followed by a chest tube insertion is needed. A chest x-ray would delay treatment and is not needed prior to emergent intervention. Administration of IV fluids would not assist with blood pressure, as increased thoracic pressure from the tension pneumothorax needs to be relieved to restore cardiac output (and blood pressure). Endotracheal intubation and mechanical ventilation may be necessary after the tension pneumothorax is relieved to assist with the patient's ventilation. DIF: Cognitive Level: Analysis OBJ: Describe assessment and management of common traumatic injuries. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

39. A patient diagnosed with anemia has a morning hematocrit level of 24% and a platelet level of 200,000/microliter. The nurse can expect to take what action? a. Continue monitoring the patient b. Administer platelets c. Give fresh frozen plasma d. Provide a red blood cell (RBC) transfusion

ANS: D Transfusion thresholds are established based on laboratory values and patient-specific variables. In general, a threshold for RBC transfusion is considered a hematocrit of 28% to 31%, based on the patient's cardiovascular tolerance. If angina or orthostasis is present, a higher threshold may be maintained. The threshold for transfusing platelets is usually between 20,000 and 50,000/microliter. Cryoprecipitate is usually infused if the fibrinogen level is less than 100 mg/dL. Fresh frozen plasma is used to correct a prolonged prothrombin time and partial thromboplastin time or a specific factor deficiency. DIF: Cognitive Level: Analysis OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

21. The nurse understands that when clots breakdown in a patient diagnosed with a hematological disorder, that which value will increase? a. Hemoglobin b. White blood cell count c. Vitamin K d. Fibrin split products

ANS: D When plasmin digests fibrinogen, fragments known as fibrin split products, or fibrin degradation products, are produced and function as potent anticoagulants. Fibrin split products are not normally present in the circulation but are seen in some hematological disorders as well as with thrombolytic therapy. Vitamin K is necessary for synthesis of factors II, VII, IX, X that are needed for clotting to occur. Hemoglobin may decrease if the patient is bleeding, and WBCs are not relevant to this scenario. DIF: Cognitive Level: Understand OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity