NUR 221 exam 3

A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much fluid should this patient receive over the first eight hours after the burn occurred? Record your answer as a whole number

6460 mL

The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected? A. Increased pH B. Increased sodium C. Increased potassium D. Decreased hematocrit

C. Increased potassium

What is the most likely site to have a sheet graft applied? A. Arm B. Face C. Leg D. Chest

B. Face

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.)

1500 mL/hr

A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/minute. The label on the infusion bag states: dobutamine 250 mg in 250 mL normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many mL per hour?

27 mL/hr

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

27%

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.)

333 drops/min

What condition does the nurse recognize as an early sign of distributive shock? A. Hypotension B. Skin warm and flushed C. Oliguria D. Cold, clammy skin

B. Skin warm and flushed

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? A. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. B. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration C. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest D. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

A. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings.

The nurse explains the purpose of an infusion of albumin 5% to a patient recovering from hypovolemic shock. Which statement indicates that the patient understands the instructions? A. "It is a protein that pulls water into my blood vessels." B. "It is a protein that causes my kidneys to conserve fluid." C. "It is a super-concentrated salt solution that helps me conserve body fluid." D. "It is a liquid that has electrolytes in it to pull water into my blood vessels."

A. "It is a protein that pulls water into my blood vessels."

A patient with several deep partial thickness burns asks how long it will take for the burn to heal. What should the nurse respond to this patient? A. "More than two weeks." B. "Within one to two weeks." C. "Within 24 to 72 hours." D. "You will need skin grafts."

A. "More than two weeks."

The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? A. "The action of the machine will improve blood supply to the damaged heart." B. "The machine will beat for the damaged heart with every beat until it heals." C. "The machine will help cleanse the blood of impurities that might damage the heart." D. "The machine will remain in place until the patient is ready for a heart transplant."

A. "The action of the machine will improve blood supply to the damaged heart."

Which patient should the nurse assess first? A. A patient with smoke inhalation who has wheezes and altered mental status B. A patient with full-thickness leg burns who has a dressing change scheduled C. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain D. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

A. A patient with smoke inhalation who has wheezes and altered mental status

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) A. Administer analgesics. B. Prevent wound infections. C. Provide fluid replacement. D. Decrease core temperature. E. Initiate physical therapy.

A. Administer analgesics. B. Prevent wound infections. C. Provide fluid replacement

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? A. Administer the prescribed intravenous morphine sulfate. B. Apply ice to skin around the burn wound for 20 minutes. C. Administer prescribed intramuscular ketorolac (Toradol). D. Decrease tactile stimulation near the burn injuries.

A. Administer the prescribed intravenous morphine sulfate.

A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which problems should the nurse anticipate providing continuing care to this patient? Select all that apply. A. Anxiety B. Depression C. Spiritual distress D. Body image disorder E. Post-traumatic stress disorder (PTSD)

A. Anxiety B. Depression D. Body image disorder E. Post-traumatic stress disorder (PTSD)

A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient? Select all that apply. A. Apply bacitracin ointment B. Cover with a nonadherent bandage C. Apply mafenide acetate 10% cream D. Wash with antiseptic soap and warm water E. Apply collagenase and cover with roll gauze

A. Apply bacitracin ointment B. Cover with a nonadherent bandage D. Wash with antiseptic soap and warm water

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? A. Apply oxygen and continuous pulse oximetry. B. Provide small quantities of ice chips and sips of water. C. Request a prescription for an antitussive medication. D. Ask the respiratory therapist to provide humidified air.

A. Apply oxygen and continuous pulse oximetry.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? A. Continue to monitor the urine output. B. Monitor for increased white blood cells (WBCs). C. Assess that blisters and edema have subsided. D. Prepare the patient for discharge from the burn unit.

A. Continue to monitor the urine output.

A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? A. Creatinine B. Red blood cells C. Sodium D. Magnesium

A. Creatinine

A patient recovering from 25% total body surface area burns has a low grade fever. What should the nurse do to reduce this patient's risk of developing an infection? A. Follow contact precautions B. Implement protective isolation C. Use sterile technique for all dressing changes D. Administer prophylactic antibiotics as prescribed

A. Follow contact precautions

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? A. Give PRN furosemide (Lasix) 40 mg IV. B. Increase normal saline infusion to 250 mL/hr. C. Administer hydrocortisone (Solu-Cortef) 100 mg IV. D. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.

A. Give PRN furosemide (Lasix) 40 mg IV.

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? A. Give normal saline IV at 500 mL/hr. B. Give acetaminophen (Tylenol) 650 mg rectally. C. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. D. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.

A. Give normal saline IV at 500 mL/hr.

A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question? A. Infuse normal saline at 250 mL/hr. B. Keep head of bed elevated to 30 degrees. C. Hold nitroprusside (Nipride) if systolic BP <90 mm Hg. D. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

A. Infuse normal saline at 250 mL/hr

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

A. Insert a feeding tube and initiate enteral feedings.

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? A. It is normal to feel some depression. B. I will go back to work immediately. C. I will not feel anger about my situation. D. Once I get home, things will be normal.

A. It is normal to feel some depression.

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? A. Keep the water temperature constant when showering the client. B. Assess the wound beds during the hydrotherapy treatment. C. Apply a topical enzyme agent after bathing the client. D. Use sterile saline to irrigate and clean the clients wounds.

A. Keep the water temperature constant when showering the client.

The nurse is caring for a patient who sustained chemical burns. What would have caused these injuries? Select all that apply. A. Lime B. Gasoline C. Bleach D. Fabric softener E. Hydrofluoric acid

A. Lime B. Gasoline C. Bleach E. Hydrofluoric acid

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.) A. Provide at least 5000 kcal/day. B. Start an oral diet on the first day. C. Administer a diet high in protein. D. Collaborate with a registered dietitian. E Offer frequent high-calorie snacks.

A. Provide at least 5000 kcal/day. C. Administer a diet high in protein. D. Collaborate with a registered dietitian. E Offer frequent high-calorie snacks.

An older adult patient is recovering in the intensive care unit (ICU) from septicemia. Which intervention will help prevent further infection for this patient? A. Provide oral and skin care B. Implement sterile wound care C. Encourage turn, cough, and deep breathe every shift. D. Place the Foley drainage on the bed at the patient's feet

A. Provide oral and skin care

An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? A. Remove nonadherent clothing and watch. B. Apply an alkaline solution to the affected area. C. Place cool compresses on the area of exposure. D. Cover the affected area with dry, sterile dressings.

A. Remove nonadherent clothing and watch.

The nurse is preparing an educational tool to instruct community members on burn prevention. What should the nurse include as the most common injury in children under age 5? A. Scald B. Flame C. Chemical D. Carbon monoxide poisoning

A. Scald

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) A. Slower healing time Increased risk for loss of function from contracture formation B. Reduced inflammatory response Deep partial-thickness wound with minimal exposure C. Reduced thoracic compliance Increased risk for atelectasis D. High incidence of cardiac impairments Increased risk for acute kidney injury E. Thinner skin May not exhibit a fever when infection is present

A. Slower healing time Increased risk for loss of function from contracture formation C. Reduced thoracic compliance Increased risk for atelectasis D. High incidence of cardiac impairments Increased risk for acute kidney injury

Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? A. The patient's central venous pressure is 3 mm Hg. B. The patient is in sinus tachycardia at 120 beats/min. C. The patient is receiving low dose dopamine (Intropin). D. The patient has had no urine output since being admitted.

A. The patient's central venous pressure is 3 mm Hg

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? A. Use aseptic technique when caring for invasive lines or devices. B. Ambulate postoperative patients as soon as possible after surgery. C. Remove indwelling urinary catheters as soon as possible after surgery. D. Advocate for parenteral nutrition for patients who cannot take oral feedings. E. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

A. Use aseptic technique when caring for invasive lines or devices. B. Ambulate postoperative patients as soon as possible after surgery. C. Remove indwelling urinary catheters as soon as possible after surgery. E. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to A. administer oxygen. B. obtain a 12-lead electrocardiogram (ECG). C. obtain the blood pressure. D. check the level of consciousness.

A. administer oxygen.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? A. Obtain the blood pressure. B. Stabilize the cervical spine. C. Assess for the contact points. D. Check alertness and orientation.

B. Stabilize the cervical spine.

The nurse is caring for a patient diagnosed with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? A. Blood transfusion with packed red blood cells is required. B. Hemoglobin and hematocrit results indicate hemodilution. C. Fluid resuscitation has resulted in fluid volume overload. D. Fluid resuscitation has resulted in third spacing of fluid.

B. Hemoglobin and hematocrit results indicate hemodilution.

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."

B. "Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal."

What may cause hypovolemic shock in children? Select all that apply. A. Hyperthermia B. Burns C. Vomiting or diarrhea D. Hemorrhage E. Skin abscess that cultures positive for methicillin-resistant Staphylococcus aureus (MRSA)

B. Burns C. Vomiting or diarrhea D. Hemorrhage

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? A. Use a disposable blood pressure cuff to avoid sharing with other clients. B. Change gloves between wound care on different parts of the clients body. C. Use the closed method of burn wound management for all wound care. D. Advocate for proper and consistent handwashing by all members of the staff.

B. Change gloves between wound care on different parts of the clients body.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? A. Increase the clients oxygen and obtain blood gases. B. Draw blood for a carboxyhemoglobin level. C. Increase the clients intravenous fluid rate. D. Perform a thorough Mini-Mental State Examination.

B. Draw blood for a carboxyhemoglobin level.

The nurse is caring for a patient with 70% total body surface area chemical burns. Which approach should the nurse anticipate to meet this patient's nutritional needs? A. Parenteral nutrition B. Duodenal tube feedings C. Nasogastric tube feedings D. Six small high-calorie meals per day

B. Duodenal tube feedings

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

B. Elevate the right arm and hand on pillows and extend the fingers.

You are the nurse caring for a child who is diagnosed with septic shock. He begins to develop an dysrhythmia and hemodynamic instability. Endotracheal intubation is necessary. The physician feels that cardiac arrest may soon develop. What drug do you anticipate the physician will order? A. Atropine sulfate B. Epinephrine C. Sodium bicarbonate D. Inotropic agents

B. Epinephrine

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

B. Full-thickness skin destruction

A patient has full-thickness burns over 30% of total body surface area. Which intervention will least likely provide comfort initially to this patient? A. Elevate injured extremities B. Medicate for pain around the clock C. Apply medicated ointment to all areas D. Elevate the head of the bed 30 degrees

B. Medicate for pain around the clock

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? A. Check temperature every 2 hours. B. Monitor breath sounds frequently. C. Maintain patient in supine position. D. Assess skin for flushing and itching.

B. Monitor breath sounds frequently.

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

B. Notify the health care provider and prepare for endotracheal intubation.

After change-of-shift report in the progressive care unit, who should the nurse care for first? A. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases B. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics C. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute D. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

B. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics

A patient recovering from full thickness burns rates pain as a 9 on a scale of 0 to 10 when hydrotherapy is performed. For which type of pain should this patient be treated? A. Referred B. Procedural C. Background D. Breakthrough

B. Procedural

A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment made by the nurse would indicate that wound care treatment has been successful? A. Gray wound bed B. Separation of eschar C. Development of eschar D. Presence of purulent exudate

B. Separation of eschar

The nurse is administering intravenous norepinephrine at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. What assessment finding requires immediate action by the nurse? A. Blood pressure 100/60 mm Hg B. Swelling at the IV site C. Heart rate of 110 beats/min D. Central venous pressure (CVP) of 8 mm Hg

B. Swelling at the IV site

The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following primary care provider rounds, the nurse reviews the orders and questions which order? A. Administer acetaminophen 650-mg suppository prn every 6 hours for pain. B. Titrate dopamine intravenously for blood pressure less than 90 mm Hg systolic. C. Complete neurological assessment every 4 hours for the next 24 hours. D. Administer furosemide 20 mg IV every 4 hours for a CVP greater than 20 mm Hg.

B. Titrate dopamine intravenously for blood pressure less than 90 mm Hg systolic.

The nurse is providing care to a patient who is admitted with cardiogenic shock. The nurse administers the prescribed atropine with no results. Which prescription does the nurse anticipate from the health-care provider based on this data? A. A beta blocker B. Transcutaneous pacing C. Cardiac defibrillation D. A preload reducer

B. Transcutaneous pacing

The nurse has just completed the assessment of a patient admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this patient? A. Ineffective Coping B. Deficient Fluid Volume C. Decreased Cardiac Output D. Ineffective Airway Clearance

C. Decreased Cardiac Output

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?"

C. "Do you have a heart condition or heart failure?"

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."

C. "Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound."

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

C. 14 L 154 pounds/2.2 = 70 kg 4 ´ 70 kg ´ 50 = 14,000 mL, or 14 liters.

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? A. 9% B. 18% C. 27% D. 36%

C. 27%

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? A. 350 mL/hour B. 523 mL/hour C. 938 mL/hour D. 1250 mL/hour

C. 938 mL/hour

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? A. A patient admitted with abdominal pain and an elevated white blood cell count B. A patient with a temperature of 102° F and a general dermal rash C. A patient with a 2-day history of nausea, vomiting, and diarrhea D. A patient with slight rectal bleeding from inflamed hemorrhoids

C. A patient with a 2-day history of nausea, vomiting, and diarrhea

A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? A. Inspiratory crackles. B. Cool, clammy extremities. C. Apical heart rate 45 beats/min. D. Temperature 101.2° F (38.4° C).

C. Apical heart rate 45 beats/min

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

C. Extremity movement

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? A. I will allow my spouse to change my dressings. B. I want to have surgical reconstruction. C. I will bathe and dress before breakfast. D. I have secured the pressure dressings as ordered.

C. I will bathe and dress before breakfast.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? A. You should change the batteries in your smoke detector once a year. B. Join a program that assists burn clients to reintegration into the community. C. I will demonstrate how to change your wound dressing for you and your family. D. Let me tell you about the many options available to you for reconstructive surgery.

C. I will demonstrate how to change your wound dressing for you and your family.

An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next? A. Increase the rate for the dopamine (Intropin) infusion. B. Decrease the rate for the nitroglycerin (Tridil) infusion. C. Increase the rate for the sodium nitroprusside (Nipride) infusion. D. Decrease the rate for the 5% dextrose in normal saline (D5 /.9 NS) infusion.

C. Increase the rate for the sodium nitroprusside (Nipride) infusion.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? A. Monitor urine output every 4 hours. B. Continue to monitor the laboratory results. C. Increase the rate of the ordered IV solution. D. Type and crossmatch for a blood transfusion.

C. Increase the rate of the ordered IV solution.

A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient? A. Increased zone of stasis B. Increased zone of hyperemia C. Increased zone of coagulation D. Decreased zone of coagulation

C. Increased zone of coagulation

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond? A. Tagamet stimulates intestinal movement so you can eat more. B. It improves fluid retention, which helps prevent hypovolemic shock. C. It helps prevent stomach ulcers, which are common after burns. D. Tagamet protects the kidney from damage caused by dehydration.

C. It helps prevent stomach ulcers, which are common after burns.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? A. Assess oral temperature. B. Check a potassium level. C. Place on cardiac monitor. D. Assess for pain at contact points.

C. Place on cardiac monitor.

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? A. Insert two large-bore IV catheters. B. Initiate continuous electrocardiogram (ECG) monitoring. C. Provide oxygen at 100% per non-rebreather mask. D. Draw blood to type and crossmatch for transfusions.

C. Provide oxygen at 100% per non-rebreather mask.

A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment? A. Skin warm and moist B. Pedal pulses present but faint C. Scattered areas of scarring noted D. Nonpitting edema of both ankles

C. Scattered areas of scarring noted

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

C. Serum potassium 6.1 mEq/L

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? A. Arterial pH: 7.32 B. Hematocrit: 52% C. Serum potassium: 6.5 mEq/L D. Serum sodium: 131 mEq/L

C. Serum potassium: 6.5 mEq/L

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? A. I get my chimney swept every other year. B. My hot water heater is set at 120 degrees. C. Sometimes I wake up at night and smoke. D. I use a space heater when it gets below zero.

C. Sometimes I wake up at night and smoke.

Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? A. The patient's urine output is 18 mL/hr. B. The patient's heart rate is 110 beats/minute. C. The patient is complaining of chest pain. D. The patient's peripheral pulses are weak.

C. The patient is complaining of chest pain.

A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? A. With reconstructive surgery, you can look the same. B. We can remove the scars with the use of a pressure dressing. C. You will not look exactly the same but cosmetic surgery will help. D. You shouldnt start worrying about your appearance right now.

C. You will not look exactly the same but cosmetic surgery will help.

The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain A. hypothermia blanket. B. lactated Ringer's solution. C. two 14-gauge IV catheters. D. dopamine (Intropin) infusion.

C. two 14-gauge IV catheters.

In which order will the nurse take these actions when doing a dressing change for a partial- thickness burn wound on a patient's chest? A. Apply sterile gauze dressing. B. Document wound appearance. C. Apply silver sulfadiazine cream. D. Administer IV fentanyl (Sublimaze). E. Clean wound with saline-soaked gauze.

D E C A B

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

D. "Do you think dark beige makeup foundation would cover this scar on my cheek?"

The nurse is conducting medication teaching for a patient who is prescribed an epi-pen. Which statements made by the patient indicates the need for additional instruction? A. "I will carry an epi-pen with me at all times." B. "I will check the expiration date on my epi-pen regularly." C. "I should hold the epi-pen in place for 10 seconds after injection." D. "I should use the epi-pen to inject the drug into my abdominal wall."

D. "I should use the epi-pen to inject the drug into my abdominal wall."

The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient? A. Chest x-ray B. Bronchoscopy C. CT scan of the head D. 12-lead electrocardiogram

D. 12-lead electrocardiogram

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

D. Apply water-based cream to burned areas frequently.

The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicates that additional fluid resuscitation is required? A. Blood pH 7.39 B. Heart rate 112 bpm C. Blood pressure 110/60 mm Hg D. Central venous pressure 2 mm Hg

D. Central venous pressure 2 mm Hg

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? A. Auscultate bowel sounds. B. Palpate for abdominal pain. C. Ask the patient about nausea. D. Check stools for occult blood.

D. Check stools for occult blood.

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? A. Document the findings and reassess in 1 hour. B. Loosen any constrictive dressings on the chest. C. Raise the head of the bed to a semi-Fowlers position. D. Gather appropriate equipment and prepare for an emergency airway.

D. Gather appropriate equipment and prepare for an emergency airway.

The nurse is reviewing the medication administration record (MAR) on a patient with partial- thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? A. Ketorolac (Toradol) B. Lorazepam (Ativan) C. Gabapentin (Neurontin) D. Hydromorphone (Dilaudid)

D. Hydromorphone (Dilaudid)

During the initial stages of shock, what are the physiological effects of decreased cardiac output? A. Arterial vasodilation B. High urine output C. Increased parasympathetic stimulation D. Increased sympathetic stimulation

D. Increased sympathetic stimulation

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? A. Placing the pulse oximeter on the ear for a patient with septic shock B. Keeping the head of the bed flat for a patient with hypovolemic shock C. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR D. Maintaining the room temperature at 66° to 68° F for a patient with neurogenic shock

D. Maintaining the room temperature at 66° to 68° F for a patient with neurogenic shock

It is documented that a patient has superficial partial-thickness burns over both anterior lower arms. What should the nurse expect when assessing this patient? A. Dry with no blisters B. Waxy appearance and cherry red in color C. Dry leathery appearance and pale or brown in color D. Open or closed blisters, mild edema, easily blanches

D. Open or closed blisters, mild edema, easily blanches

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? A. Heart rate B. Orientation C. Blood pressure D. Oxygen saturation

D. Oxygen saturation

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? A. Administer furosemide (Lasix). B. Perform chest physiotherapy. C. Document and reassess in an hour. D. Place the client in an upright position.

D. Place the client in an upright position.

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

D. Place the patient on 100% oxygen using a non-rebreather mask.

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication? A. Bowel sounds B. Stool frequency C. Abdominal distention D. Stools for occult blood

D. Stools for occult blood

During the initial stage of shock, which clinical manifestation should the nurse monitor for when assessing the patient? A. Lethargy B. Hypotension C. Respiratory alkalosis D. Subtle changes in heart rate

D. Subtle changes in heart rate

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? A. Blood pressure is 95/48 per arterial line. B. Serous exudate is leaking from the burns. C. Cardiac monitor shows a pulse rate of 108. D. Urine output is 20 mL per hour for the past 2 hours.

D. Urine output is 20 mL per hour for the past 2 hours.

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

D. Use pulse oximetry to check the oxygen saturation.

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? A. Administer the prescribed tetanus toxoid vaccine. B. Assess the clients wounds for signs of infection. C. Encourage the client to breathe deeply every hour. D. Wash your hands on entering the clients room.

D. Wash your hands on entering the clients room.

A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? A. When the antibiotic therapy is complete. B. As soon as his albumin levels return to normal. C. Once we complete the fluid resuscitation process. D. When all of his burn wounds have closed.

D. When all of his burn wounds have closed.

The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO 2 28 mm Hg, HCO 3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? A. pH 7.40, CO 2 40, HCO 3 24 B. pH 7.45, CO 2 45, HCO 3 26 C. pH 7.35, CO 2 40, HCO 3 22 D. pH 7.30, CO 2 45, HCO 3 18

D. pH 7.30, CO 2 45, HCO 3 18

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) A. Obtain blood and urine cultures. B. Give vancomycin (Vancocin) 1 g IV. C. Start norepinephrine (Levophed) 0.5 mcg/min. D. Infuse normal saline 2000 mL over 30 minutes. E. Titrate oxygen administration to keep O2 saturation >95%.

E D C A B

A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury? A. Coughing B. Soot on the face C. Singed facial hair D. Heart rate 98 bpm

C. Singed facial hair

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the helth care provider? A. Blood pressure (BP) 92/56 mm Hg B. Skin cool and clammy C. Oxygen saturation 92% D. Heart rate 118 beats/minute

B. Skin cool and clammy

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

600 mL

A patient is prescribed epinephrine for the prevention of anaphylactic shock. The patient states, "I thought shock was about heart failure." Which response by the nurse is most appropriate? A. "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." B. "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." C. "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure." D. "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure."

A. "There are many kinds of shock that also include infection, nervous system damage, and loss of blood."

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

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.

A patient with 35% total body surface area burns is in the rehabilitative phase of care. Which approach should be used to reduce the risk of developing contractures? A. Apply splints B. Physical therapy two hours a day C. Passive range of motion exercises D. Occupational therapy one hour every other day

A. Apply splints

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.

A. Apply topical antibacterial wound ointments/dressings C. Daily assess the need for central IV catheters. E. Maintain strict aseptic technique during burn wound management.

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

A. Applying splints that maintain the extremity in an extended position B. Implementing passive or active range-of-motion exercises D. Wrapping fingers and toes individually with bandages

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) A. Ask all family members and visitors to perform hand hygiene before touching the client. B. Carefully monitor burn wounds when providing each dressing change. C. Clean equipment with alcohol between uses with each client on the unit. D. Allow family members to only bring the client plants from the hospitals gift shop. E. Use aseptic technique and wear gloves when performing wound care.

A. Ask all family members and visitors to perform hand hygiene before touching the client. B. Carefully monitor burn wounds when providing each dressing change. E. Use aseptic technique and wear gloves when performing wound care.

The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? A. Assess the blood pressure palpation B. Estimate the systolic pressure as 60 mm Hg. C. Obtain an electronic blood pressure monitor. D. Record the blood pressure as "not assessable."

A. Assess the blood pressure palpation

The nurse is administering albumin 5% to a patient in shock. Which nursing action is appropriate when assessing this patient? A. Auscultate breath sounds for crackles B. Auscultate breath sounds for hyperresonance C. Auscultate breath sounds for inspiratory stridor D. Auscultate for an absence of breath sounds in the lower lobes

A. Auscultate breath sounds for crackles

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? A. Auscultate the patient's lung sounds. B. Determine the extent and depth of the burns. C. Infuse the ordered lactated Ringer's solution. D. Administer the ordered hydromorphone (Dilaudid).

A. Auscultate the patient's lung sounds.

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO 2 ) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The primary care provider orders stat administration of an antibiotic. Which additional order should the nurse complete first? A. Blood cultures B. Chest x-ray C. Foley insertion D. Serum electrolytes

A. Blood cultures

The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) A. Blood pressure B. Heart rate C. Level of consciousness D. Pupil response E. Respirations F. Urine output

A. Blood pressure C. Level of consciousness F. Urine output

Which will the nurse closely monitor due to the pathophysiology associated with early shock? Select all that apply. A. Bowel sounds B. Level of consciousness C. Urine output D. Peripheral pulses E. Heart rate

A. Bowel sounds C. Urine output D. Peripheral pulses

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? A. Cardiac index (CI) of 2.5 L/min/m 2 B. Pulmonary artery diastolic pressure of 26 mm Hg C. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg D. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm 5

A. Cardiac index (CI) of 2.5 L/min/m 2

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? A. Central nervous system B. Gastrointestinal system C. Renal system D. Respiratory system

A. Central nervous system

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

A. Central nervous system deficits

A patient is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this patient for when administering the infusion? Select all that apply. A. Confusion B. Tachycardia C. Disorientation D. Muscle spasms E. Gastrointestinal bleeding

A. Confusion B. Tachycardia C. Disorientation D. Muscle spasms

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m 2 . What is the priority pharmacological intervention? A. Dobutamine B. Furosemide C. Phenylephrine D. Sodium nitroprusside

A. Dobutamine

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central line associated bloodstream infection (CLABSI)? A. Documentation of insertion date B. Elevation of the head of the bed C. Assessment for weaning readiness D. Appropriate sedation management

A. Documentation of insertion date

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? A. High pulmonary artery diastolic pressure and low cardiac output B. Low pulmonary artery occlusive pressure and low cardiac output C. Low systemic vascular resistance and high cardiac output D. Normal cardiac output and low systemic vascular resistance

A. High pulmonary artery diastolic pressure and low cardiac output

A nurse is caring for a patient who was involved in a motor vehicle accident who has lost approximately 1,500 mL of blood. Based on this data, which type of shock is the patient experiencing? A. Hypovolemic B. Cardiogenic C. Distributive D. Obstructive

A. Hypovolemic

The nurse is preparing an educational session on sepsis. Which should the nurse include as a major risk factor for the development of this health problem? A. Immunosuppression B. Elevated temperature C. Pneumococcal bacteria D. Leukocytosis on the complete blood count

A. Immunosuppression

The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO 2 ) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? A. Insertion of an 18-gauge peripheral intravenous line B. Application of cushioned heel protectors C. Implementation of fall precautions D. Implementation of universal precautions

A. Insertion of an 18-gauge peripheral intravenous line

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

A. Involves a joint. B. Involves the face, hands, or feet. D. Requires more than 2 weeks for healing.

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

A. Long bone fractures B. Cardiac dysrhythmias D. Compartment syndrome of extremities E. Dark brown urine G. Acute cataract formation H. Seizures

The nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a patient with septicemia. Which intervention will address this patient's health problem? A. Monitor for cyanosis. B. Monitor heart rate every hour. C. Assess temperature every four hours. D. Monitor pupil reactions every eight hours.

A. Monitor for cyanosis.

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) A. Music as a distraction B. Tactile stimulation C. Massage to injury sites D. Cold compresses E. Increasing client control

A. Music as a distraction B. Tactile stimulation E. Increasing client control

The school nurse is preparing material for National Fire Prevention week. What information should be added to the classroom posters? Select all that apply. A. Never leave a burning candle unattended. B. Set heating pads on "low" when sleeping. C. Keep a flashlight and telephone near the bed. D. Check smoke alarm batteries every six months. E. Never use the oven as a method to warm the home.

A. Never leave a burning candle unattended. C. Keep a flashlight and telephone near the bed. D. Check smoke alarm batteries every six months. E. Never use the oven as a method to warm the home.

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? A. New onset of confusion B. Heart rate 112 beats/minute C. Decreased bowel sounds D. Pale, cool, and dry extremities

A. New onset of confusion

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? A. Notify the health care provider. B. Monitor the pulses every 2 hours. C. Elevate both legs above heart level with pillows. D. Encourage the patient to flex and extend the toes on both feet.

A. Notify the health care provider

Which assessment findings would indicate to the nurse that a patient is exhibiting early symptoms of shock? Select all that apply. A. Pallor B. Increased bowel sounds C. Restlessness D. Decreased blood glucose E. Increased respiratory rate

A. Pallor C. Restlessness E. Increased respiratory rate

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? A. Prepare to administer atropine IV. B. Obtain baseline body temperature. C. Infuse large volumes of lactated Ringer's solution. D. Provide high-flow oxygen (100%) by non-rebreather mask. E. Prepare for emergent intubation and mechanical ventilation.

A. Prepare to administer atropine IV. B. Obtain baseline body temperature. D. Provide high-flow oxygen (100%) by non-rebreather mask. E. Prepare for emergent intubation and mechanical ventilation.

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.

A. Remove the patient's clothes and flush the area with water.

A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with late septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. A. Shallow respirations B. Lethargic mental status C. Decreased urine output D. Normal blood pressure E. Warm and flushed skin F. Rapid and deep respirations

A. Shallow respirations B. Lethargic mental status C. Decreased urine output

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

A. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound.

The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate of 45 beats/min, and respirations of 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? A. The patient is developing neurogenic shock. B. The patient is experiencing an allergic reaction. C. The patient most likely has an elevated temperature. D. The vital signs are normal for this patient.

A. The patient is developing neurogenic shock.

A patient in neurogenic shock is receiving rapid intravenous fluids. Which assessment finding indicates the need for additional nursing interventions? A. The patient's mean arterial pressure (MAP) is 60 mmHg. B. The patient is unconscious. C. The patient has received two liters of infused fluid. D. The patient is perspiring heavily.

A. The patient's mean arterial pressure (MAP) is 60 mmHg.

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? A. The patient's serum creatinine level is elevated. B. The patient complains of intermittent chest pressure. C. The patient's extremities are cool and pulses are weak. D. The patient has bilateral crackles throughout lung fields.

A. The patient's serum creatinine level is elevated.

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

A. Toxic epidermal necrolysis

Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? A. Hemoglobin is within normal limits. B. Urine output is 60 mL over the last hour. C. Central venous pressure (CVP) is normal. D. Mean arterial pressure (MAP) is 72 mm Hg.

B. Urine output is 60 mL over the last hour.

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

C. Infection

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.

B. Remove excessive wound fluid and promote moist wound healing.

The nurse is evaluating nutritional teaching provided to a patient recovering from 24% total body surface area burns. Which information indicates that teaching has been effective? A. Weight loss 3 kg B. Serum protein level 7.1 g/dL C. Serum albumin level 2.8 g/dL D. +1 pitting edema of lower extremities

B. Serum protein level 7.1 g/dL

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

B. "It's true that your life may be different. What concerns you the most?"

The nurse is preparing to administer diphenhydramine to a patient who is experiencing a severe allergic reaction to peanuts. Which information about the drug should the nurse provide to the patient? A. "This is the medication of choice to treat airway obstruction." B. "This medication will help relieve your itching and runny nose." C. "This medication will prevent you from going into anaphylactic shock." D. "This medication will take a while to be effective but will control your symptoms for several hours."

B. "This medication will help relieve your itching and runny nose."

A nurse working in the intensive care unit (ICU) is caring for a patient in refractory stage of shock. When planning care, which does the nurse anticipate? A. A subtle change in heart rate B. A change from aerobic to anaerobic metabolism C. The development of hyperglycemia D. The development of cardiac dysrhythmias

B. A change from aerobic to anaerobic metabolism

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

B. Active and passive range of motion every hour

The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? A. Patient response to therapy is appropriate. B. Additional interventions are indicated. C. More time is needed to assess response. D. Values are normal for the patient condition.

B. Additional interventions are indicated.

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? A. Increase intravenous fluids by 100 mL/hr. B. Administer furosemide (Lasix) 40 mg IV push. C. Continue to monitor urine output hourly. D. Draw blood for serum electrolytes STAT.

B. Administer furosemide (Lasix) 40 mg IV push.

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.

B. Ask the caregiver to step out while examining the patient's burn injury

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

B. Bedrest C. Burns to lower extremities E. Delayed fluid resuscitation

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

B. Body image disturbance

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) A. Administer acetaminophen B. Document the patient's response. C. Increase the rate of transfusion. D. Notify the blood bank. E. Notify the physician. F. Stop the transfusion.

B. Document the patient's response. D. Notify the blood bank. E. Notify the physician. F. Stop the transfusion.

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

B. Electrical burn

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? A. Diphenhydramine 50 mg intravenously B. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously C. Methylprednisolone 125 mg intravenously D. Ranitidine 50 mg intravenously

B. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously

A patient is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this patient? Select all that apply. A. Pain B. Fever C. Edema D. Anorexia E. Tachycardia

B. Fever D. Anorexia E. Tachycardia

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication? A. 5% human albumin B. Furosemide (Lasix) IV C. Epinephrine (Adrenalin) drip D. Hydrocortisone (Solu-Cortef)

B. Furosemide (Lasix) IV

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? A. Start a normal saline infusion. B. Give epinephrine (Adrenalin). C. Start continuous ECG monitoring. D. Give diphenhydramine (Benadryl).

B. Give epinephrine (Adrenalin).

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.

B. Inhalation injury above the glottis may cause significant edema that obstructs the airway.

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.

B. Is effective against a wide spectrum of wound pathogens

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? A. Creatinine 1.0 mg/dL B. Lactate 6 mmol/L C. Potassium 3.8 mEq/L D. Sodium 140 mEq/L

B. Lactate 6 mmol/L

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

B. Methamphetamine use

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m 2 , heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm 5 . Upon review of primary care provider orders, which order is most appropriate for the nurse to initiate? A. Furosemide 20 mg intravenous (IV) every 4 hours as needed for CVP &gt; 20 mm Hg B. Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain C. Dobutamine infusion at a rate of 2 to 20 mcg/kg/min as needed for CI &lt; 2 L/min/m 2 D. Dopamine infusion at a rate of 5 to 10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

B. Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain

A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with early septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. A. Shallow respirations B. Normal blood pressure C. Warm and flushed skin D. Lethargic mental status E. Decreased urine output F. Rapid and deep respirations

B. Normal blood pressure C. Warm and flushed skin F. Rapid and deep respirations

The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic, hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient? A. Starting two large intravenous catheters B. Notifying the Rapid Response Team C. Calling the patient's physician to report the changes D. Placing oxygen on the patient

B. Notifying the Rapid Response Team

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

B. Posttraumatic stress disorder

Which is the highest priority nursing action when providing care to a patient with shock? A. Starting two large intravenous catheters B. Recognizing early clinical manifestations C. Administering high-flow oxygen D. Calling for help immediately

B. Recognizing early clinical manifestations

A nurse assesses a client admitted with deep partial-thickness and full thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? A. Partial pressure of arterial oxygen (PaO2 ) of 80 mm Hg B. Urine output of 20 mL/hr C. Productive cough with white pulmonary secretions D. Core temperature of 100.6 F (38 C)

B. Urine output of 20 mL/hr

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? A. Use sterile gloves when removing old dressings. B. Wear gowns, caps, masks, and gloves during all care of the patient. C. Administer IV antibiotics to prevent bacterial colonization of wounds. D. Turn the room temperature up to at least 70° F (20° C) during dressing changes.

B. Wear gowns, caps, masks, and gloves during all care of the patient

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for A. nitroglycerine (Tridil). B. norepinephrine (Levophed). C. sodium nitroprusside (Nipride). D. methylprednisolone (Solu-Medrol).

B. norepinephrine (Levophed).

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

C. Intraabdominal hypertension

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? A. Administration of atropine sulfate B. Application of 100% oxygen via facemask C. Application of slow rewarming measures D. Infusion of IV phenylephrine

C. Application of slow rewarming measures

The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? A. Administer pain medication. B. Turn patient every 2 hours. C. Assess core body temperature. D. Apply bilateral heel protectors.

C. Assess core body temperature.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? A. Assess the level of consciousness and pupillary reactions. B. Ascertain the time food or liquid was last consumed. C. Auscultate breath sounds over the trachea and bronchi. D. Measure abdominal girth and auscultate bowel sounds.

C. Auscultate breath sounds over the trachea and bronchi.

The nurse is providing care for a patient receiving treatment for cardiogenic shock. Which assessment finding indicates that the compensatory mechanism of vasoconstriction has occurred in this patient? A. Increased heart rate B. Increased injection fraction C. Decreased urine output D. Decreased temperature

C. Decreased urine output

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? A. Frequent turning B. Monitoring intake and output C. Enteral feedings D. Pain management

C. Enteral feedings

An older adult patient is experiencing hypovolemic shock. Which is the priority intervention for this patient? A. Assessing the cause of bleeding B. Providing replacement of volume C. Establishing invasive cardiac monitoring D. Administering analgesics for control of pain

C. Establishing invasive cardiac monitoring

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

C. Hourly intake and urine output

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

C. Increased capillary permeability

A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? A. Human albumin infusion B. Hypotonic saline solution C. Lactated Ringer's bolus D. Packed red blood cells

C. Lactated Ringer's bolus

A patient recovering from deep and full thickness burns is nauseated. Which medication should the nurse provide to help this patient? A. Ranitidine (Zantac) B. Esomeprazole (Nexium) C. Metoclopramide (Reglan) D. Polyethylene glycol (Miralax)

C. Metoclopramide (Reglan)

The nurse is concerned that a patient is demonstrating early signs of hypovolemic shock. Which assessment findings support the nurse's concern? Select all that apply. A. Rapid weak pulse B. Normal respirations C. Normal blood pressure D. Slight increase in pulse E. Prolonged capillary refill time

C. Normal blood pressure D. Slight increase in pulse E. Prolonged capillary refill time

The nurse is providing care to a patient admitted to the emergency department (ED) with a gunshot wound and profound blood loss. Which order does the nurse anticipate for this patient? A. Normal saline B. Dextrose in water C. Packed red blood cells D. Albumin

C. Packed red blood cells

A patient develops hypovolemic shock secondary to pancreatitis. Which action by the nurse is most appropriate? A. Starting an 18-gauge intravenous catheter in the patient's nondominant hand B. Ordering a type and cross-match of packed red blood cells C. Preparing to assist with central line placement D. Inserting a nasogastric tube

C. Preparing to assist with central line placement

The nurse is providing care to a patient who is admitted to the emergency department with symptoms of a myocardial infarction (MI). Which is the primary purpose of the interventions administered to this patient? A. Providing pain relief B. Preventing extension of damage C. Preventing cardiogenic shock D. Reducing blood pressure

C. Preventing cardiogenic shock

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of &gt;2.5 L/min/m 2 . The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m 2 . What is the best action by the nurse? A. Obtain a stat serum potassium level. B. Order a stat 12-lead electrocardiogram. C. Reduce the rate of dobutamine. D. Assess the patient's hourly urine output.

C. Reduce the rate of dobutamine.

The patient with neurogenic shock is receiving a phenylephrine (Neo Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? A. The patient's heart rate is 58 beats/minute. B. The patient's extremities are warm and dry. C. The patient's IV infusion site is cool and pale. D. The patient's urine output is 28 mL over the last hour.

C. The patient's IV infusion site is cool and pale.

The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse? A. Administer blood transfusion over at least 4 hours. B. Notify the physician of the elevated temperature. C. Titrate rate of blood administration to patient response. D. Notify the physician of the patient's heart rate.

C. Titrate rate of blood administration to patient response.

A patient comes into the emergency room seeking treatment for radiation burns. What should be considered prior to providing care to this patient? A. Pathway of flow through the body B. Duration of contact with the agent C. Type, dose, and length of exposure D. Temperature to which the skin is heated

C. Type, dose, and length of exposure

A patient being treated for hypovolemic shock is prescribed a low dose of dopamine. Which outcome does the nurse anticipate for this patient? A. Increased cardiac output B. Stabilization of fluid loss C. Urinary output of at least 30 mL/hour D. Vasoconstriction and increased blood pressure

C. Urinary output of at least 30 mL/hour

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

C. Vanilla milkshake

A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective? A. No new heart murmurs B. Decreased troponin level C. Warm, pink, and dry skin D. Blood pressure 92/40 mm Hg

C. Warm, pink, and dry skin

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.

D. Tissue edema may interfere with drug absorption of injectable routes

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?"

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?"

A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if this patient is experiencing carbon monoxide poisoning? A. Chest x-ray B. Bronchoscopy C. Pulse oximeter D. Carboxyhemoglobin level

D. Carboxyhemoglobin level

A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this patient? A. Increase oral fluids B. Turn in bed every two hours C. Monitor strict intake and output D. Deep breathing and coughing every hour

D. Deep breathing and coughing every hour

The nurse is caring for a patient who sustained electrical burns. Why should the nurse monitor this patient for compartment syndrome? A. Potential for undiagnosed injuries B. Injuries from being thrown bruise soft tissue C. Electrical current alters integrity of blood vessels D. Fluid seeps from intravascular spaces into the interstitium

D. Fluid seeps from intravascular spaces into the interstitium

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first? A. Acetaminophen suppository B. Blood cultures from two sites C. IV antibiotic administration D. Isotonic fluid challenge

D. Isotonic fluid challenge

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? A. High pulmonary artery occlusive pressure and high cardiac output B. High systemic vascular resistance and low cardiac output C. Low pulmonary artery occlusive pressure and low cardiac output D. Low systemic vascular resistance and high cardiac output

D. Low systemic vascular resistance and high cardiac output

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

D. Measure hourly urine output.

A client is admitted with possible sepsis. Which action should the nurse perform first? A. Administer antibiotics. B. Give an antipyretic. C. Place the client in isolation. D. Obtain specified cultures.

D. Obtain specified cultures.

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

D. Release of myoglobin from injured tissues

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal- directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? A. Breath sounds and capillary refill B. Blood pressure and oral temperature C. Oral temperature and capillary refill D. Right atrial pressure and urine output

D. Right atrial pressure and urine output

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.

D. Stop the burning process and prevent further injury. 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.

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? A. The assessed values are within normal limits. B. The patient is at risk for developing cardiogenic shock. C. The patient is at risk for developing fluid volume overload. D. The patient is at risk for developing hypovolemic shock.

D. The patient is at risk for developing hypovolemic shock.

The nurse is providing care to a patient diagnosed with hypovolemic shock. Which nursing action is appropriate for this patient during the initial compensatory phase? A. Placing a cool blanket over the patient B. Raising the patient's head to a 30-degree angle C. Positioning the patient in the left-lateral recumbent position D. Turning the patient's head to one side if no neck injury is suspected

D. Turning the patient's head to one side if no neck injury is suspected

The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn shock is resolving? A. Heart rate 112 bpm B. Respirations 24 per minute C. Blood pressure 90/60 mm Hg D. Urine output 800 mL over 2 hours

D. Urine output 800 mL over 2 hours

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? A. Normal body temperature B. Balanced intake and output C. Adequate pain management D. Urine output of 0.5 mL/kg/hr

D. Urine output of 0.5 mL/kg/hr