quiz 1 practice questions

Water weight calculation/equivalents?

1 L = 1 kg = 2.2 lb

A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? SELECT ALL THAT APPLY. A. Use a potassium infusion prepared by a registered pharmacist. B. Assess for burning or redness during infusion. C. Infuse at a rate of no more than 10 mEq per hour. D. Administer only through a central venous catheter. E. Administer by IV push only during cardiac arrest.

A, B, C Interventions to safely administer KCl to a client with hypokalemia include: using a pharmacy prepared potassium infusion, checking the client for any burning or redness during infusion, and infusing the IV at not more than 10 mEq per hour. The Joint Commission's National Client Safety Goals mandates that concentrated potassium be diluted and added to IV solutions only in the pharmacy by a registered pharmacist and that vials of concentrated potassium not be available in client care areas. IV potassium solutions irritate veins and cause phlebitis. Assess the IV site hourly, and ask the client whether he or she feels burning or pain at the site. The presence of pain or burning at the insertion site may require a new intravenous to be started. A dose of KCl 5-10 mEq/hour, no more than 20 mEq/hr is recommended.Potassium may be administered by peripheral or central vein. There is no circumstance where potassium is given by IV push.

A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? SELECT ALL THAT APPLY. A. Place the client on bed rest. B. Evaluate the electrolyte levels. C. Administer the ordered diuretic. D. Assess for orthostatic hypotension E. Initiate cardiac monitoring.

A, B, D, E Nursing actions indicated at this time include: placing the client on bedrest and assisting the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension, and applying a cardiac monitor. Safety is required to prevent falls due to weakness from a likely fluid volume deficit and electrolyte imbalance. The nurse should review the laboratory and diagnostic results to detect likely loss of sodium, potassium, and magnesium secondary to diarrhea and diuretic use. Fluid volume deficit is likely with diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially hypokalemia. Assessing for orthostatic changes will confirm the presence of volume deficit. Monitoring for inverted T wave or presence of U wave on the ECG as well as dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of fluids and electrolytes. The nurse would question this order in the presence of assessment data indicating fluid loss from the diuretics and diarrhea.

You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration? A. Extravasation of the medication B. Discomfort to the patient C. Blanching at the site D. Hypersensitivity reaction to the medication

A. Extravasation of the medication Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences.

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patient's care? A. Fluid status B. Risk of infection C. Nutritional status D. Psychosocial coping

A. Fluid status During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A. Hemodynamic instability B. Gastrointestinal hypermotility C. Respiratory arrest D. Hypokalemia

A. Hemodynamic instability (blood/circulation/fluid balance issue) The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.

The body response to burn injury has been classified as A. Hyperdynamic response, hypermetabolic response, and hypercatabolic response B. Hyperdynamic response, hypometabolic response, and hypermetabolic response C. Hypodynamic response, hypermetabolic response, and hypermetabolic response D. Hypodynamic response, hypometabolic response, and hypometabolic response

A. Hyperdynamic response, hypermetabolic response, and hypercatabolic response

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B. Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C. Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D. Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid d/t cell damage, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration (water follows salt - there is not enough Na b/c it's trapped and permeability increases so fluid leaks out and we lose sodium too) that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A. Metabolic acidosis The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

A patient's most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis? A. Risk for imbalanced fluid volume related to low albumin B. Risk for infection related to low albumin C. Ineffective tissue perfusion related to low albumin D. Impaired skin integrity related to low albumin

A. Risk for imbalanced fluid volume related to low albumin Albumin (helps with oncotic pressure that draws fluid into the bloodstream and keeps it inside the blood vessel) is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly always manifest as fluid imbalances b/c there's not enough albumin to pull enough fluid and fluid leaves the intravascular space causing low volume. Tissue oxygenation and skin integrity are not normally affected. Low albumin does not constitute a risk for infection.

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A. Sodium deficit (d/t fluid shifts and it affects water and Na) B. Decreased prothrombin time (PT) C. Potassium deficit D. Decreased hematocrit

A. Sodium deficit (d/t fluid shifts and it affects water and Na) Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, base-bicarbonate deficit, and elevated hematocrit. PT does not typically decrease.

During a blood culture, which one do you draw first?

Aerobic bacteria specimen d/t the excess air in the needle

A client with hypokalemia is to receive intravenous (IV) potassium replacement. Which action should the nurse take when administering potassium intravenously? Select all that apply. A. Administer potassium by IV push. B. Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration. C. Monitor complete blood count during potassium infusion. D. Follow the facility policy for infusion of potassium. E. Report a reduced urinary output to the health care provider.

B, D, E Potassium should be administered by an infusion pump and should never be given by IV push to avoid rapid replacement. Because potassium is excreted by the kidneys, BUN, serum creatinine, and urinary output should be assessed prior to and during administration of IV potassium. Abnormal laboratory results or decreased or absent urinary output should be reported to the health care provider. Because potassium administration does not affect blood cells, the complete blood count does not need to be monitored during administration of potassium. The nurse should check facility policy on the administration of IV potassium to ensure safe care.

The community health nurse is performing a home visit to an 80-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? A. "I will need to have your medications adjusted, so you will need to be readmitted to the hospital for a complete workup." B. "Limiting your fluids can create imbalances that can result in confusion, so let's try adjusting the timing of your fluids." C. "It is normal to be a little confused following surgery, and it is safe not to urinate at night." D. "Confusion and bladder issues are a normal consequence of aging, so I am not too concerned."

B. "Limiting your fluids can create imbalances that can result in confusion, so let's try adjusting the timing of your fluids." In older adult clients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the older adult. There is no specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in older adults.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which of the following interventions should the nurse perform for this complication? A. Elevate the client's head B. Apply a warm compress C. Position the client on the left side D. Apply antiseptic and a dressing

B. Apply a warm compress Prolonged use of the same vein can cause phlebitis; the nurse should apply warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if the client exhibits signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

The physician has ordered a PIV to be inserted before the client goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? A. Choose a hairless site if possible B. Consider potential effects on the clients mobility when selecting a site C. Have the client briefly hold his arm over his head before insertion D. Leave the tourniquet on for at least 3 minutes

B. Consider potential effects on the clients mobility when selecting a site Ideally, both arms and hands are inspected closely before insertion of an IV catheter. Instruct the patient to hold their arm in a dependent position to increase blood flow. Never leave a tourniquet on for more than 2 minutes. The site does not have to be devoid of hair

A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurses most appropriate action? A. Apply an icepack to the blood that remains to be infused. B. Discontinue the remainder of the PRBC transfusion and inform the physician. C. Disconnect the bag of PRBCs, cool for 30 minutes and then administer. D. Administer the remaining PRBCs by the IV direct (IV push) route.

B. Discontinue the remainder of the PRBC transfusion and inform the physician. Because of the risk of infection, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route. Max hang time is 4 hrs and should be administered within 30 mins out the fridge to avoid infection/contamination.

Why aren't full-thickness burns generally pain-free? A. They aren't. All burns have the same level of pain. B. Full-thickness burn involve the epidermis, dermis, and the subcutaneous tissue destroying nerve ending C. Modern medical procedures relieve much of the pain of full-thickness burns

B. Full-thickness burn involve the epidermis, dermis, and the subcutaneous tissue destroying nerve ending

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member? A. Hes on a calorie-restricted diet in order to divert energy to wound healing. B. His body has consumed his fat deposits for fuel because his calorie intake is lower than normal. C. He actually hasn't lost weight. Instead, there's been a change in the distribution of his body fat. D. He lost many fluids while he was being treated in the emergency phase of burn care.

B. His body has consumed his fat deposits for fuel because his calorie intake is lower than normal. Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Patients are not placed on a calorie restriction during recovery and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur.

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A. Hydrostatic pressure B. Osmosis and osmolality C. Diffusion D. Active transport

B. Osmosis and osmolality

A patient undergoing a hip replacement has autologous (own pt's blood) blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A. Safe transfusion for patients with a history of transfusion reactions B. Prevention of viral infections from another persons blood C. Avoidance of complications in patients with alloantibodies D. Prevention of alloimmunization

B. Prevention of viral infections from another persons blood The primary advantage of autologous transfusions is the prevention of viral infections from another persons blood. Other secondary advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in patients with alloantibodies.

The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve which of the following procedures? A. A spontaneous separation of dead tissue from the viable tissue (natural debridement not mechanical) B. Removal of eschar until the point of pain and bleeding occurs C. Shaving of burned skin layers until bleeding, viable tissue is revealed D. Early closure of the wound

B. Removal of eschar until the point of pain and bleeding occurs Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accomplished through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Shaving the burned skin layers and early wound closure are examples of surgical debridement.

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Increased PaCO2 D. CNS disturbances

B. Respiratory alkalosis (CO2 = acid, and blowing off acid --> more alkalotic) The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload.

The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A. Notify the patients physician. B. Stop the transfusion immediately. C. Remove the patients IV access. D. Assess the patients chest sounds and vital signs.

B. Stop the transfusion immediately. Transfusion reaction is happening. Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patients vital signs, and notify the physician. The blood container and tubing should be sent to the blood bank to analyze what caused this. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The patients IV access should not be removed b/c we might have to infuse NS or other rescue meds.

A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patients adverse reaction? A. Antibodies to donor leukocytes remained in the blood (febrile). B. The donor blood was incompatible with that of the patient. C. The patient had a sensitivity reaction to a plasma protein in the blood (allergic). D. The blood was infused too quickly and overwhelmed the patient's circulatory system

B. The donor blood was incompatible with that of the patient. An acute hemolytic reaction occurs when the donor blood (ABO specific) is incompatible with that of the recipient. In the case of a febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic reaction.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss B. Flat neck and hand veins C. An increase in blood pressure D. Decreased central venous pressure (CVP)

C. An increase in blood pressure A fluid volume is also known as over hydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion? A. Leave one hand ungloved to assess the site. B. Cleanse the skin with normal saline. C. Ask the patient about allergies to latex or iodine. D. Remove excessive hair from the selected site.

C. Ask the patient about allergies to latex or iodine. Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in preparing for IV therapy. A local reaction could result in irritation to the IV site, or, in the extreme, it could result in anaphylaxis, which can be life threatening. Both hands should always be gloved when preparing for IV insertion, and latex-free gloves must be used or the patient must report not having latex allergies. The skin is not usually cleansed with normal saline prior to insertion. Removing excessive hair at the selected site is always secondary to allergy inquiry.

A patient's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? A. Have the patient identify his or her blood type in writing. B. Ensure that the patient has granted verbal consent for transfusion. C. Assess the patient's vital signs to establish baselines. D. Facilitate insertion of a central venous catheter.

C. Assess the patient's vital signs to establish baselines. Prior to a transfusion, the nurse must take the patients temperature, pulse, respiration, and BP to establish a baseline. Written consent is required and the patients blood type is determined by type and cross match, not by the patients self-declaration. PIV transfusion is okay (18-22 is minimum). Peripheral venous access is sufficient for blood transfusion.

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site? A. Leave the hair intact B. Shave the area C. Clip the hair in the area D. Remove the hair with a depilatory

C. Clip the hair in the area Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following? A. Help distinguish hyponatremia from hypernatremia B. Help evaluate pituitary gland function C. Help distinguish reduced renal blood flow from decreased renal function D. Help provide an effective treatment for hypertension-induced oliguria

C. Help distinguish reduced renal blood flow from decreased renal function If a patient is not secreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a patient with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor? A. Overhydration is common among healthy older adults. B. Dehydration causes the skin to appear spongy. C. Inelastic skin turgor is a normal part of aging. D. Skin turgor cannot be assessed in patients over 70.

C. Inelastic skin turgor is a normal part of aging. Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.

While assessing a client's peripheral IV site, the nurse observes edema and coolness around the insertion site. How should the nurse document this observation? A. Air embolism B. Phlebitis C. Infiltration D. Fluid overload

C. Infiltration Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness, and a significant decrease in the flow rate. An air embolism occurs when air enters the vein; it does not have any local manifestations at the IV site but may produce palpitations, dyspnea, hypotension, and chest pain. Phlebitis, an inflammation of the vein, is characterized by redness, warmth, and tenderness at the IV site. Fluid volume overload produces systemic manifestations and is not apparent at the IV site.

A patient has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the patient's consequent increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what substance? A. Vitamin E B. Vitamin D C. Iron D. Magnesium

C. Iron To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased. Iron is important for formation of RBCs. Body can usually recycle iron but females have lower hgb & hct d/t menstrual cycle.

Examples of colloids vs. crystalloids

Colloids: Albumin, dextran, blood products Crystalloids: NS, LR, D5W

A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A. Activity Intolerance B. Anxiety C. Ineffective Coping D. Acute Pain

D. Acute Pain Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid, the presence of pain may contribute to these diagnoses. Management of the patients pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses.

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A. Pain B. Fluid balance C. Anxiety and fear D. Airway management

D. Airway management (smoke irritates lining of airway and cause swelling that will disrupt airway -> may require intubation) Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A. Superficial partial-thickness B. Deep partial-thickness C. Full partial-thickness D. Full-thickness

D. Full-thickness A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the patient will experience pain that is soothed by cooling b/c nerve is still intact. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the patient will complain of pain and sensitivity to cold air. Full partial thickness is not a depth of burn.

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A. Active transport of hydrogen ions across the capillary walls B. Pressure of the blood in the renal capillaries C. Action of the dissolved particles contained in a unit of blood D. Hydrostatic pressure resulting from the pumping action of the heart

D. Hydrostatic pressure resulting from the pumping action of the heart Hydrostatic pressure is the pressure created by the weight of fluid against the wall that contains it. In the body, hydrostatic pressure in blood vessels results from the weight of fluid itself and the force resulting from cardiac contraction. This pressure causes water and electrolytes from the arterial capillary bed to pass into the interstitial fluid, in this instance, as a result of the pumping action of the heart; this process is known as filtration. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration.

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? A. Metabolic alkalosis B. Hypermagnesemia C. Hypercalcemia D. Hypovolemia

D. Hypovolemia Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A. Respiratory acidosis with no compensation B. Metabolic alkalosis with a compensatory alkalosis C. Metabolic acidosis with no compensation D. Metabolic acidosis with a compensatory respiratory alkalosis

D. Metabolic acidosis with a compensatory respiratory alkalosis A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.

Early signs of hypervolemia include A. Decrease in BP B. Thirst C. Moist breath sounds D. Weight gain and increased breathing effort

D. Weight gain and increased breathing effort Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst

Based on what you know about Central vs. Peripheral perfusion, how can you determine when a pt is experiencing EARLY vs. LATE signs of ECV depletion/fluid volume deficit?

Early: peripheral perfusion changes (extremities and non vital organs); capillary refill, skin, peripheral pulses Late: central perfusion changes (vital organs); Heart, brain, kidney, bp, LOC

What lab values are mainly affected by hemodynamics? (Labs related to hemoconcentration vs. hemodilution)

Hematocrit, sodium BUN Hemoconcentration will increase HSB Hemodilution will decrease HSB

S/s of hypovolemia vs. hypervolemia

Hypovolemia: increased hr, decreased bp, narrowed pulse pressure, orthostatic hypotension Hypervolemia: high bp, increased hr, distended neck veins, pulmonary edema

When a pt becomes hypovolemic, which vital sign increases and which one decreases? Why?

Increase in HR (heart tries to compensate for volume loss) Decrease in BP (d/t volume loss)

During venipuncture, the pt suddenly experiences extreme burning or pain, electric shock sensation, numbness, and/or pain that radiates down the arm. What do you do FIRST?

Remove the needle immediately; this is related to nerve damage

Prevention of shock and respiratory distress are two immediate priorities of care during the emergent/resuscitation phase burn injury. T/F

True