MEG SURG EXAM 1 PREPU

Which pulse pressure indicates shock? 120/90 mm HG 130/80 mm HG 100/60 mm HG 90/70 mm HG

90/70 mm HG

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? Between 100 and 200 mL <30 mL Between 75 and 100 mL >200 mL

<30 mL

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? Full-thickness Superficial partial-thickness Superficial Deep partial-thickness

Full-thickness

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema? Generalized Dependent Brassy Pitting

Generalized

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? Hypokalemia Hypocalcemia Hyperkalemia Hypercalcemia

Hypercalcemia

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis

Metabolic acidosis

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first? Place a pressure dressing over the opening and secure. Moisten sterile gauze with normal saline and place on the protruding organ. Have the client lay quietly on back and call the physician. Place a dry, sterile dressing over the protruding organs.

Moisten sterile gauze with normal saline and place on the protruding organ.

The nurse is assessing a postoperative patient's abdominal wound and observes a portion of intestines protruding through the wound. What is the priority intervention for the nurse to provide? Approximate the wound edges with adhesive tape so that the intestines can be gently pushed back into the abdomen. Carefully push the exposed intestines back into the abdominal cavity. Apply an abdominal binder snugly so that the intestines can be slowly pushed back into the abdominal cavity. Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? The client's breathing is unlabored, and skin is clammy. The client is alert and conscious. The client's heart rate is rapid and regular. The client's urinary output is 0.3 to 0.5 mL/kg/hour.

The client's urinary output is 0.3 to 0.5 mL/kg/hour

A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which client statement indicates an accurate understanding of appropriate ways to deal with this deficit? "I'll bowl with my team after discharge." "I'll take a long trip to visit my aunt." "I'll play card games with my friends." "I'll eat lunch in a restaurant every day.

"I'll play card games with my friends."

hypovolemic good response

"increased capillary permeability causes fluid shifts out of the blood vessels and results in hypovolemia"

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first? C-spine x-rays 100% oxygen via a nonrebreather mask Two large-bore IVs and begin crystalloid fluids Type and cross match

100% oxygen via a nonrebreather mask

Adequate hourly urine output for a client with an indwelling urinary catheter is 2.0 mL/kg/h. 1.5 mL/kg/h. 1.0 mL/kg/h. 0.5 mL/kg/h.

2.0 mL/kg/h

The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition? 500 mL 400 mL 300 mL 600 mL

300 mL

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 36% 30% 27% 18%

36%

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. 80 mm Hg 90 mm Hg 60 mm Hg 70 mm Hg

60 mm Hg

Which is a growth-based classification of tumors? Leukemia Sarcoma Malignancy Carcinoma

Malignancy

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? Modified Trendelenburg Trendelenburg Supine Semi-Fowler's

Modified Trendelenburg

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? Diverticulitis Hematemesis Ulcerative colitis Paralytic ileus

Paralytic ileus

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pneumonia Pulmonary edema Pleurisy Hypoxemia

Pneumonia

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Obtain a urine specimen for drug screening. Monitor the client's heart rhythm. Prepare for gastric lavage

Prepare to assist with ventilation.

Which of the following is a true statement regarding the purposes of skin grafts? Increases potential for infection. Reduces scarring and contractures. Prolongs recovery Increases evaporative fluid loss

Reduces scarring and contractures.

The physician is attending to a 72-year-old client with a malignant brain tumor. The physician recommends immediate radiation therapy. What is a reason for the physician's recommendation? To prevent the formation of new cancer cells To remove the tumor from the brain To analyze the lymph nodes involved To destroy marginal tissues

To prevent the formation of new cancer cells

A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client? Wear personal protective equipment when handling blood, body fluids, and feces. Provide a urinal or bedpan to decrease the likelihood of soiling linens. Wear sterile gloves. Place incontinence pads in the regular trash container.

Wear personal protective equipment when handling blood, body fluids, and feces.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by third intention. fourth intention. first intention. second intention.

first intention.

The nurse is working with a client who has had an allohematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of acute leukopenia. graft-versus-host disease. nadir. metastasis.

graft-versus-host disease.

nurse is evaluating pt lab results, based on findings what will cause the release of ADH resulting in water conservation

increased serum sodium

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? liver dysfunction unsteady gait organ damage weight loss

organ damage

pt has alcoholism and suspect during your assessment that is serum magnesium is low; what do u asses w hypomagnesemia?

tremor

A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? Encourage the client to ambulate as soon as possible after surgery. Notify the physician. Administer a tap water enema. Apply moist heat to the client's abdomen.

Encourage the client to ambulate as soon as possible after surgery.

Which term refers to the protrusion of abdominal organs through the surgical incision? Erythema Evisceration Dehiscence Hernia

Evisceration

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. Furosemide Lansoprazole Ranitidine Famotidine (Pepcid) Desmopressin

Famotidine (Pepcid) Ranitidine Lansoprazole

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: First intention Third intention Granulation Second intention

First intention

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? Fourth intention Second intention First intention Third intention

First intention

Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? Prolonged dangling of the legs over the edge of the bed Hourly leg exercises Fluid restriction Use of blanket rolls to elevate the lower extremities

Hourly leg exercises

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "How many victims are anticipated for transport?" "Are the victims suffering from thermal burns?" "Are any of the victims expected to have electrical burns?" "Are the burns associated with chemicals used in the plant?"

"Are the burns associated with chemicals used in the plant?"

When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area? 1 2 4 3

1

The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour? 2.7 mL/hr 5.5 mL/hr 8.0 mL/hr 11 mL/hr.

2.7 mL/hr

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? Unstable angina pectoris Aortic insufficiency Hypertension Diabetes mellitus

Aortic insufficiency

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply. Extravasation Hematoma Infection Air embolism Phlebitis

Extravasation Hematoma Phlebitis

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? a. Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration b. Hanging tape on the bedside table when changing a wet-to-dry sterile dressing c. Rubbing the hands together with antiseptic solution until dry when exiting the client's room d. Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids

Hanging tape on the bedside table when changing a wet-to-dry sterile dressing

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hypernatremia. Hypoglycemia. Hyperkalemia. Hypocalcemia.

Hyperkalemia.

You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client? Decreases blood return to the heart Decreases carbon dioxide exchange Contracts bronchioles Increases myocardial contractility

Increases myocardial contractility

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? Acute incisional pain Ineffective airway clearance Decreased cardiac output Ineffective thermoregulation

Ineffective thermoregulation

Which of the following is the effect of protein catabolism in a client with severe burns? It compromises dexterity and mobility. It compromises wound healing and immunocompetence. It maximizes the risk of sodium retention and hypotension. It maximizes the risk of impaired ventilation.

It compromises wound healing and immunocompetence.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? Polyuria Tetanic contractions Weight loss Jugular vein distention

Jugular vein distention

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. Listening to music Watching television Changing position An epidural infusion An On-Q pump

Listening to music Watching television Changing position

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess Mental status Lung sounds Skin perfusion Bowel sounds

Lung sounds

What is the highest priority nursing intervention for a client in the immediate postoperative phase? Maintaining a patent airway Monitoring vital signs at least every 15 minutes Assessing urinary output every hour Assessing for hemorrhage

Maintaining a patent airway

A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate? Notify the physician. Ambulate the client to reduce abdominal distention. Administer morphine per orders. Inform the client this is the normal progression after abdominal surgery.

Notify the physician

In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting? Phase IV PACU Phase II PACU Phase III PACU Phase I PACU

Phase II PACU

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? White with long, thin areas of scar tissue Pink to red and soft, noting that it bleeds easily Pale yet able to blanch with digital pressure Necrotic and hard

Pink to red and soft, noting that it bleeds easily

The nurse is caring for a client who develops an evisceration. What nursing intervention is most appropriate when an evisceration occurs in the surgical wound of a client who has undergone surgery? A. Administer prescribed analgesics. B. Place the client in a position that puts the least strain on the operative area. C. Place sterile dressings moistened with normal saline over the protruding organs and tissues. D. Instruct the client to avoid any movement.

Place sterile dressings moistened with normal saline over the protruding organs and tissues

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? Position the client to maintain a patent airway. Assess the incisional dressing to detect hemorrhage. Monitor vital signs for early detection of shock. Administer antiemetics to prevent nausea and vomiting.

Position the client to maintain a patent airway

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? Sodium Potassium CO2 Chloride

Potassium

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client? Elevation ofblood pressure and heart rate Presence of soot around nasal passages Fracture of the fibula with displacement Partial-thickness burns to hands and wrists

Presence of soot around nasal passage

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to circumferential eschar Related to femoral artery occlusion Related to infection Related to fat emboli

Related to circumferential eschar

Which of the following arterial blood gas results would be consistent with metabolic alkalosis? PaCO2 less than 35 mm Hg pH 7.26 Serum bicarbonate of 28 mEq/L Serum bicarbonate of 21 mEq/L

Serum bicarbonate of 28 mEq/L

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? All options are correct. deep tissue cooling continuing inflammatory process protein cell coagulation

deep tissue cooling

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound pustulated. dehisced. hemorrhaged. eviscerated.

dehisced

pt is receiving large volumes of crystalloid fluid to treat shock, the nurse should monitor for

hypothermia

pt with severe inhalation burns has been receiving treatments for 24 hours. when assessing the pt, what findings would indicate R distress? increased agitation increased rate of breathing increased sleep increased water intake restlessness

increased agitation increased rate of breathing increased water intake restlessness

The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing: orthostatic hypotension acute pain incisional pain anxiety

orthostatic hypotension

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? pH 7.48 O saturation 95% HCO 21 mEq/L PaCO 36

pH 7.48

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: metabolic alkalosis. respiratory alkalosis. metabolic acidosis. respiratory acidosis

respiratory alkalosis.

When vasoactive medications are administered, the nurse must monitor vital signs at least how often? 30 minutes Hourly 45 minutes 15 minutes

15 minutes

A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames? 6 weeks 8 weeks 1 week 2 to 4 weeks

2 to 4 weeks

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 27% 18% 45% 36%

27%

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr A urinary output of 10 mL/hr

A urinary output of 30 mL/hr

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? Abdominal distention Increased abdominal girth Abdominal tightness Absence of peristalsis

Absence of peristalsis

Which colloid is expensive but rapidly expands plasma volume? Dextran Hypertonic saline Lactated Ringer solution Albumin

Albumin

When should the nurse encourage the postoperative patient to get out of bed? On the second postoperative day Between 10 and 12 hours after surgery As soon as it is indicated Within 6 to 8 hours after surgery

As soon as it is indicated

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? Administering pain medications within 1 hour of the client's request Obtaining dietary consultation for improved wound healing Educating the client on safe bed-to-chair transfer procedures Assessing WBC count, temperature, and wound appearance

Assessing WBC count, temperature, and wound appearance

Which type of vaccine uses the client's own cancer cells, which are killed and prepared for injection back into the client? Therapeutic Autologous Allogeneic Prophylactic

Autologous

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? Prepare to administer a stool softener. Call the health care provider. Prepare to insert a nasogastric tube. Re-attempt to auscultate bowel sounds.

Call the health care provider

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? Hypovolemic Carcinogenic Circulatory (distributive) Obstructive

Circulatory (distributive)

A side-effect of chemotherapy is renal damage. To prevent this, the nurse should: Withhold medication when the blood urea nitrogen level exceeds 20 mg/dL. Encourage fluid intake, if possible, to dilute the urine. Modify the diet to acidify the urine, thus preventing uric acid crystallization. Limit fluids to 1,000 mL/day to minimize stress on the renal tubules.

Encourage fluid intake, if possible, to dilute the urine.

pt is about undergo hydrotherapy to remove necrotic tissue what meds would u give

IV morphine sulfate

Oral intake is controlled by the thirst center, located in which of the following cerebral areas? Brainstem Cerebellum Thalamus Hypothalamus

Hypothalamus

According to the tumor-node-metastasis (TNM) classification system, T0 means there is No distant metastasis No regional lymph node metastasis Distant metastasis No evidence of primary tumor

No evidence of primary tumor

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: NS at 60 mL/hr via an intravenous line Dopamine (Intropin) intravenous solution Morphine 2 mg intravenously Oxygen at 2 L/min by nasal cannula

Oxygen at 2 L/min by nasal cannula

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings? Respiratory alkalosis Metabolic alkalosis Metabolic acidosis Respiratory acidosis

Respiratory alkalosis

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? There are no advantages of patient-controlled analgesia over a PRN dosing schedule. The client can self-administer oral pain medication as needed with patient-controlled analgesia. Family members can be involved in the administration of pain medications with patient-controlled analgesia. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? Cover the client with a wet cloth. Place the client with the head positioned slightly below the rest of the body. Roll the client in a blanket. Avoid immediate IV fluid therapy.

Roll the client in a blanket

A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection? Stage 3 pressure ulcer on the left heel Temperature of 98.3° F (36.8° C) White blood cell (WBC) count of 9,000 cells/mm3 Ate 75% of all meals during the day

Stage 3 pressure ulcer on the left heel

Which oncologic emergency involves the failure in the negative feedback mechanism that normally regulates the release of antidiuretic hormone (ADH)? Cardiac tamponade Disseminated intravascular coagulation (DIC) Syndrome of inappropriate antidiuretic hormone release (SIADH) Tumor lysis syndrome

Syndrome of inappropriate antidiuretic hormone release (SIADH

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? Vasodilation Tachycardia Increased urine output Bradycardia

Tachycardia

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? The paramedic administered high doses of opioids during transport. The client is in hypovolemic shock. The client has experienced extensive full-thickness burns. The client has experienced partial-thickness burns.

The client has experienced extensive full-thickness burns.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? It helps determine the percentage of the total body surface area (TBSA) that is burned. The wound is susceptible to infections. The client's condition is likely to deteriorate after 72 hours. The early appearance of the burn injury may change.

The early appearance of the burn injury may change.

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) Urinary output Vital signs Visual acuity Mental status Ability to perform range of motion exercises

Urinary output Mental status Vital signs

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? dehydration hyperkalemia hypervolemia hypercalcemia

Urine pH of 3.0

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Specific gravity of 1.02 Absence of protein Urine pH of 3.0 Absence of glucose

Urine pH of 3.0

As the first priority of care, a patient with a burn injury will initially need: pain medication administered. an indwelling catheter inserted. fluids replaced. a patent airway established.

a patent airway established

pt has chronic renal failure, lab results show hypocalcemia and hyperphosphatemia; nurse should be alert for these S/S

cardiac arrhyhmias fractures trousseau's sign

first aid for burns

covering burn with clean dry dressing

pt diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH), nurse should assess for

decreased serum sodium

preggers pt recieved dose of magnesium sulfate for eclampsia which assessment finding would indicate pt now has hypermagnesmia

diminished deep tendon reflexes

pt has suffered MI, what assessment should nurse do first

dysrhythmias

pt with hypokalemia and heart failutre is admitted to telemetry unit, nurse is aware this can cause

elevated U wave

pt has second degree burn, which layers does nurse suspect for damage

epidermis and dermis

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? perineal face, neck, chest hands, major joints All options are correct.

face, neck, chest

pt admitted with septic shock has a normal BP, and cold/ clammy skin the pt is

in compensatory stage of shock

severe burn its should include

limiting visitors, increase protein intake, restrict fresh flowers

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? Pericardiocentesis Thoracotomy with chest tube insertion Administration of oxygen via venture mask Intubation and mechanical ventilation

ntubation and mechanical ventilation

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? ranitidine chlorpromazine omeprazole ondansetron

ondansetron

pt is receiving dopamine to increase stroke volume for shock, the nurse should be aware of

the drug dose needs to be weened off prior to discontinuation

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting? anasarca hypovolemia third-spacing pitting edema

third-spacing

The nurse is evaluating bloodwork results of a client with cancer who is receiving chemotherapy. The client's platelet count is 60,000/mm3. Which is an appropriate nursing action? Providing commercial mouthwash to the client Taking the client's temperature rectally Avoiding the use of products containing aspirin Providing a razor so the client can shave

voiding the use of products containing aspirin

What measurement should the nurse report to the physician in the immediate postoperative period? A hemoglobin of 13.6 A systolic blood pressure lower than 90 mm Hg A temperature reading between 97°F and 98°F Respirations between 20 and 25 breaths/min

A systolic blood pressure lower than 90 mm Hg

A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first? Administer an epinephrine injection as ordered by the health care provider. Obtain the name and information of the allergic substance. Call 911. Obtain a health history.

Administer an epinephrine injection as ordered by the health care provider.

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is a. A middle-aged woman with metastatic breast cancer and a BMI of 26 b. An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection c. An older adult man with end-stage renal disease and an infected dialysis access site d. A young female adolescent who developed shock from tampon use during menses

An older adult man with end-stage renal disease and an infected dialysis access site

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? Chest pain Jaundice Hypertension Slow pulse

Chest pain

The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply. Atelecstasis Hematoma Paralytic ileus Thrombophlebitis Dehiscence

Dehiscence Hematoma