review

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis?

Metabolic alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg; hypercapnia, not hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). With respiratory acidosis the pH will be less than 7.35.

A patient is admitted with a diagnosis of cellulitis of the left leg and has been placed on antibiotics. Which laboratory result is the best indicator that the treatment is having a positive outcome for the patient?

WBC of 8200/μL The normal white blood cell count is generally 4000 to 11,000/μL. For this reason, the patient's level would be returning to normal if it was 8200/μL, indicating recovery from cellulitis. The 2900/µL is too low and indicates another problem is occurring. The 12,700/µL and 16,300/µL are evidence of continuing infection.

The nurse observes no P waves on the patients monitor strip. There are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. What does the nurse determine the rhythm to be?

Atrial fibrillation Correct Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/min with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply.

Confusion Excessive thirst Fruity-scented breath Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). Diabetic ketoacidosis develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to diabetic ketoacidosis if untreated. Signs and symptoms include excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion. Frequent urination, not decreased urination, is a symptom. Weakness or fatigue, not hyperactivity, is a symptom.

A client's arterial blood gas report indicates the pH is 7.52, PCO 2 is 32 mm Hg, and HCO 3 is 24 mEq/L. What does the nurse identify as a possible cause of these results?

Excessive mechanical ventilation The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.

In reviewing the chart, which patient assessment is likely to have the greatest impact on this patient's risk of death from the accident?

Left pupil 10 cm, not reactive to light Unilateral pupil dilation without response to light can be a clinical indicator of tentorial herniation of the brain and can occur in a surfing accident as the surfboard and patient are forcefully tossed around in the waves. If the excessive intracranial pressure is allowed to continue, the patient is at a high risk for brainstem death. This finding merits emergency interventions to prevent death. The PAWP, sinus tachycardia with frequent PVCs, and cool extremities with weak peripheral pulses do not indicate imminent death.

An infant has been vomiting after each feeding. Physical assessment reveals poor skin turgor, a sunken anterior fontanel, and tremors. The infant's acid-base balance is outside the expected range. What does the nurse suspect as the cause of this imbalance?

Loss of chloride ions through vomiting Electrolyte deficits, rather than urinary excretion, precipitate an acid-base imbalance. Loss of gastric secretions, which contain sodium, chloride, and potassium, usually results in metabolic alkalosis. With vomiting, a depletion of cellular potassium occurs. Electrolyte deficits, rather than inadequate blood supply, can precipitate an acid-base imbalance.

A male patient is brought into the emergency department with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse's priority?

Maintain personal and work place safety. Correct The nurse's priority is to maintain personal and work place safety. Violence can erupt in the emergency department when treating gang members if the rival gang seeks revenge, or the patient's gang members seek to protect the patient with their presence. Staff members can be victims of that violence, so they should maintain a safe work environment by seeking law enforcement and security assistance in maintaining safety for the staff and the patient. ABCs are the usual priority, but this situation does not show any problem with the patient's airway or breathing.

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what?

Metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. Eventually respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis may occur as a result of hyperventilation during early shock.

The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase?

Monitor for signs of complications. Correct Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

Which is an independent nursing action that should be included in the plan of care for a client after an episode of ketoacidosis?

Monitoring for signs of hypoglycemia resulting from treatment During treatment for acidosis, hypoglycemia may develop; careful observation for this complication should be made by the nurse. Withholding all glucose may cause insulin coma. Whole milk and fruit juices are high in carbohydrates, which are contraindicated immediately following ketoacidosis. The regulation of insulin depends on the prescription for coverage; the prescription usually depends on the client's blood glucose level rather than ketones in the urine.

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates?

Myocardial ischemia Correct The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave. A pacemaker's presence is evident on the ECG by a spike leading to depolarization and contraction.

Three days after experiencing a series of tick bites, a patient presents to the emergency department. Which manifestation would indicate the patient is experiencing tick paralysis?

Respiratory distress Correct A classic manifestation of tick paralysis is flaccid ascending paralysis, which develops over 1 to 2 days. Without tick removal, the patient dies as respiratory muscles become paralyzed. Aggression, decreased level of consciousness, fever, and necrosis at the bite sites are not characteristic of the problem.

Students are having an end of the semester party, which includes drinking alcohol, having snacks, and swimming. A student was found floating in the pool. Which action by first responders is most important?

Securing the airway and providing ventilation CorrectAggressive resuscitation efforts (e.g., airway and ventilation management), especially in the prehospital phase, improve survival of drowning victims. Initial evaluation involves assessment of airway, cervical spine, breathing, and circulation. Treatment of submersion injuries focuses on correcting hypoxia and fluid imbalances, supporting basic physiologic functions, and rewarming when hypothermia is present. Most drowning victims do not aspirate any liquid due to laryngospasm.

The nurse is performing an assessment for a patient undergoing radiation treatment for breast cancer. What position should the nurse place the patient to best auscultate for signs of acute pericarditis?

Sitting and leaning forward Correct A pericardial friction rub indicates pericarditis. To auscultate a pericardial friction rub, the patient should be sitting and leaning forward. The nurse will hear the pericardial friction rub at the end of expiration.

The nurse is caring for a patient admitted for uncontrolled seizures who is also diagnosed with impetigo on the face and neck. Which action is appropriate for the nurse to take?

Wash hands for 1 to 2 minutes when leaving the room. Impetigo is a bacterial skin infection with group A β-hemolytic streptococci or staphylococci. Meticulous hygiene (including hand washing) is essential to prevent the spread of infection. A particulate mask or a gown would not be necessary to prevent the spread of impetigo. Gloves would not be needed to make a delivery to the room.

A patient reports to the clinic nurse a ring-like itchy rash on the upper leg, low-grade fever, nausea, and joint pain for the past 3 weeks. What question is important for the nurse to ask the patient?

"Have you had a tick bite recently?" Correct Symptoms are consistent with Lyme disease caused by the organism Borrelia burgdorferi, which is transmitted by a tick bite. The itching would not necessarily be worse at night. Exposure to pubic lice would cause itching in the genital area and not fever, nausea, and joint pain. Unprotected sexual contact would not cause an isolated itchy rash on the upper leg.

The nurse determines there is artifact on the patient's telemetry monitor. Which factor should the nurse assess for that could correct this issue?

"I can expect redness and swelling of the incision site for a few days." Correct Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care providers immediately. Teach patients to inform TSA airport security of presence of ICD because it may set off metal detectors. If a handheld screening wand is used, it should not be placed directly over the ICD. Teach patients to avoid standing near antitheft devices in doorways of stores and public buildings and to walk through them at a normal pace. Caregivers should learn cardiopulmonary resuscitation.

The nurse is doing discharge teaching with the patient who received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that further teaching is required?

"I cannot fly because it will damage the ICD." Correct The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that informing TSA security screening agents at the airport about the ICD should be done because it may set off the metal detector and if a hand-held screening wand is used, it should not be placed directly over the ICD. The other options indicate the patient understands the teaching.

A 71-yr-old woman arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask?

"What time did you take the medication?" Correct Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons.

When computing a heart rate from the electrocardiography (ECG) tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. What does the nurse calculate the patient's heart rate to be?

100 beats/min Correct Because each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).

A nurse is caring for a client with end-stage kidney disease who is about to receive a transplant. When the client returns from the postanesthesia care unit after a kidney transplant, how often should the nurse measure the client's urinary output?

1hour Hourly output is critical in assessing kidney function; decreasing urinary output is a sign of rejection. Every 2 hours is too infrequent for monitoring output immediately after a kidney transplant; it is essential to monitor output more frequently to evaluate whether the new kidney is working or being rejected. It is not necessary to monitor every 15 or 30 minutes.

A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being?

22.5% Correct Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

A man who has 40% of the body surface area burned is admitted to the hospital. Fluid replacement of 7200 mL during the first 24 hours has been prescribed. What does the nurse calculate the hourly intravenous (IV) fluid to be? Record your answer using a whole number. ___ mL/hr

300 The total volume to be infused is 7200 mL. The total time of infusion is 24 hours. 7200/24=300

A nurse is caring for a client with endocrine problems. Which lab finding will alert the nurse that aldosterone will be released?

Hyponatremia Hyponatremia stimulates the secretion of aldosterone. Hypoglycemia inhibits the secretion of insulin. Hyperkalemia, not hypokalemia, stimulates the secretion of aldosterone. Hypochloremia is associated with increased levels of antidiuretic hormone.

A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have?

7.20 The pH of blood is maintained within the narrow range of 7.35 to 7.45. When there is an increase in hydrogen ions, the respiratory, buffer, and renal systems attempt to compensate to maintain the pH. If compensation is not successful, acidosis results and is reflected in a lower pH.

Therapeutic levels of digoxin are 0.8-2.0 ng/mL. The toxic level is____________________

>2.4 ng/mL

A nurse is performing triage in the emergency department. Which patient should the nurse see first? A 18-yr-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg A 32-yr-old patient with drug overdose who is unresponsive with a poor respiratory effort A 56-yr-old patient with substernal chest pain who is diaphoretic with shortness of breath A 78-yr-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg

A 32-yr-old patient with drug overdose who is unresponsive with a poor respiratory effort The patient with a drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last.

10. A patient is in refractory VF after multiple attempts at defibrillation, CPR, and appropriate medications have been administered. Which action should be considered next?

A. Initiate double-sequence defibrillation.

After surgical implantation of radon seeds for oral cancer, what side effects of the radiation does the nurse observe in the client?

Nausea or vomiting The mucosa of the mouth and the vomiting center in the brainstem may be affected, producing nausea and vomiting. Hematuria or occult blood and hypotension or bradycardia are not side effects of radiation therapy to the oral cavity. Neither abdominal cramping nor diarrhea is an expected response because of the distance between the radon seeds and the intestines.

3. Synchronized cardioversion is to be performed on an unstable patient with SVT. Which finding indicates instability?

B. Complaints of chest pain: Rationale: Complaints of chest pain, hypotension (rather than hypertension), altered mental status, and acute heart failure are all signs of poor perfusion that indicate instability in a patient with a tachyarrhythmia. Atrial fibrillation on the cardiac monitor does not always translate to instability; many patients are stable with atrial fibrillation. Many patients with tachycardia are stable.

When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient (select all that apply.)?

Active and passive ROM maintain function of body parts. Correct ROM will show the patient that movement is still possible. Correct Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

An 18-yr-old man who fell through the ice on a pond near his farm was admitted to the emergency department with somnolence. Vital signs are blood pressure of 82 mm Hg systolic with Doppler, respirations of 9 breaths/min, and core temperature of 90°F (32.2°C). The nurse should anticipate which intervention?

Active core rewarming Correct Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.

The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas with temperatures near 100°F (37.7°C) for the past 2 weeks. When assessing the patient, the nurse finds hypotension, body temperature of 104°F (40°C), dry and ashen skin, and neurologic symptoms. What treatments should the nurse anticipate (select all that apply.)?

Administer 100% O2. Correct Administer cool IV fluids. Correct Administer chlorpromazine for shivering. Correct The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient's ABC and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. If shivering ensues, treatment with chlorpromazine is indicated. Shivering increases core temperature due to the heat generated by muscle activity. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.

A 47-yr-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6ºF (30.3ºC). Which nursing action is most important?

Administer warmed IV fluids. Correct A patient with a core body temperature of 86.6ºF (30.3ºC) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4ºF [43ºC]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite.

An 18-yr-old young woman has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention?

Administration of activated charcoal Correct Among the most common treatments for poisoning is the administration of activated charcoal. Induced vomiting is not typically indicated, and there is no need for plasma administration. Whole-bowel irrigation may be used as an adjunct therapy later in treatment, but the use of activated charcoal is central to the treatment of poisonings.

A mass casualty incident was identified on a nearby freeway. Which patient would likely be designated "red" during triage at the site?

An individual whose femoral artery has been severed and is bleeding profusely Correct Red indicates a life-threatening injury requiring immediate intervention, such as severe bleeding. Emotional trauma would not warrant a "red" designation, and a fracture would likely be deemed "yellow," urgent but not life threatening. Those not expected to survive are categorized "blue." "Black" identifies the dead.

The nurse is teaching a patient about the application of a topical medication. What should the nurse include in the instruction for the patient?

Apply a layer of medication that is just thick enough to ensure coverage. Correct

Which nursing intervention would be most helpful in managing a patient newly admitted with cellulitis of the right foot?

Applying warm, moist heat Correct The application of warm, moist heat speeds the resolution of inflammation and infection when accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the affected area to bring macrophages to the area and carry off cellular debris. Immobilization and elevation is also used. Snug blankets would not be helpful and could decrease circulation to this sensitive tissue.

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which nursing intervention is most appropriate at this time?

Assessing the incision for any redness, swelling, or discharge Correct After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.

2. A patient is experiencing chest pain, shortness of breath, and a decreased level of consciousness. To maximize the current through the myocardium, where should the nurse place the self-adhesive defibrillator pads?

B. One pad over the right precordium and the other pad over the right scapula at the first intercostal space Rationale: Anterior-lateral placement of self-adhesive defibrillation pads is effective for monitoring and defibrillation. One pad is placed in the right infraclavicular area and the other pad on the midaxillary line over the sixth intercostal space. Proper placement of the pads promotes sufficient electrical conductivity and enhances defibrillation effectiveness. The other placements described would not maximize the current through the myocardium.

Which assessment parameter will the nurse address during the secondary survey of a patient in triage?

Blood pressure and heart rate Correct Vital signs are considered to be a part of the secondary survey in the triage process. Airway, breathing, circulation, and a brief neurologic assessment are components of the primary survey that is done to identify life-threatening conditions.

A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? Select all that apply.

Burn odor Leathery skin Cardiac arrest A client with electrical burns may have assessment findings such as burn odor, leathery skin, and cardiac arrest due to hypovolemia and electrical disturbances. Coughing and smoky breath are assessment findings associated with inhalational injuries.

A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply.

Butterfly facial rash Inflammation of the joints

1. For which patient should synchronized cardioversion be considered to terminate ventricular tachyarrhythmias?

C. A patient who has a ventricular rate greater than 150 beats per minute Rationale: Synchronized cardioversion is an electrical therapy used to terminate ventricular tachyarrhythmias. If a patient has no pulse, the AHA recommends defibrillation. A patient who is hemodynamically stable should be treated first with antiarrhythmic medications. A patient who has responded well to antiarrhythmic medications generally does not require cardioversion.

A client had a laparoscopic cholecystectomy. Postoperatively the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What should the nurse include in the teaching plan when preparing this client for discharge? Select all that apply.

Call the healthcare provider if you have a fever of 100 o F (37.8 oC) or more for two days. Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage.

A nurse is caring for a client with severe gastritis who vomited a large amount of blood. A lavage is prescribed by the healthcare provider. Which response does the nurse expect when using a room temperature irrigating solution?

Constriction of blood vessels Lavage removes blood from the stomach, and the irrigating solution produces vascular constriction, which helps control bleeding by limiting blood flow to the area. Lavage does not cause the blood to clot. Neutralization of acid by water irrigation will take time; antacids may be instilled to alter the pH. Stimulation of the vagus nerve is not the purpose of a lavage for gastric hemorrhage.

the AHA recommends emergent synchronized cardioversion in which conditions

Unstable supraventricular tachycardia SVT unstable atrial fibrillation unstable atrial flutter unstable monomorphic (regular) ventricular tachycardia *"Unstable" is defined as one or more of these: acute altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock that are likely to be secondary to the tachyarrhythmia.

4. When performing cardioversion for the treatment of SVT in a responsive adult, which action is appropriate?

D. Activating sync mode Rationale: If the sync mode is not activated, the defibrillator may deliver the shock on the T wave and cause ventricular fibrillation. For narrow complex rhythms, the initial energy setting is less than 300 J. A path of gel left between the paddles may cause an energy arc. To avoid inadvertent conduction of current to the wrong person, no one should be in contact with the patient during discharge of current.

10. During synchronized cardioversion, the monitor shows the patient's heart rhythm has deteriorated to ventricular fibrillation. What should be the nurse's next action?

D. Administer a defibrillation shock. Rationale: If the patient's rhythm has deteriorated to ventricular fibrillation and the pads are already in place, the nurse should remove the sync mode and deliver a defibrillation shock (asynchronous). This gives the patient the best chance of survival. Beginning chest compressions and administering breaths should be started immediately after the unsynchronized shock. Because the synchronized shock in cardioversion looks for a QRS complex on which to shock, the defibrillator in sync mode will probably not deliver a shock, because ventricular fibrillation does not contain QRS complexes.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement?

High-calorie and high-protein foods Correct A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

6. After synchronized cardioversion, which situation is most concerning?

D. The patient complaining of shortness of breathRationale: Shortness of breath may indicate a pulmonary embolus or other serious complication of cardioversion. General muscle soreness is a common feeling after cardioversion. A transient ST-segment elevation may be noted. Troponin levels are rarely affected by cardioversion.

The nurse prepares to defibrillate a patient. For which dysrhythmia has the nurse observed in this patient?

Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

A patient with aortic valve stenosis is being admitted for valve replacement surgery. Which assessment finding documented by the nurse is indicative of this condition?

Distended neck veins Incorrect The turbulent blood flow across a diseased valve results in a murmur. Aortic stenosis produces a systolic murmur. A pulse deficit indicates a cardiac dysrhythmia, most commonly atrial fibrillation. Distended neck veins may be caused by right-sided heart failure. Splinter hemorrhages occur in patients with infective endocarditis.

The nurse observes a flat line on the patient's monitor and the patient is unresponsive without pulse. What medications does the nurse prepare to administer?

Epinephrine and/or vasopressin Normally, the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine or vasopressin may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for ventricular tachycardia or ventricular fibrillation. Digoxin and procainamide are used for ventricular rate control. β-adrenergic blockers are used to slow heart rate, and dopamine is used to increase heart rate.

Sudden deterioration of the patient's condition may warrant rapid synchronized cardioversion or an unsynchronized shock if the patient becomes pulseless and converts to ___________________________ and _________________________

ventricular fibrillation or ventricular tachycardia

A client is admitted to the hospital with diabetic ketoacidosis. The nurse concludes that the client's elevated ketone level is caused by incomplete oxidation of which nutrient?

Fats Incomplete oxidation of fat results in fatty acids that further break down to ketones. Protein metabolism produces nitrogenous waste, causing elevated blood urea nitrogen (BUN), not ketones. Potassium is not oxidized; potassium is not directly associated with ketones. Carbohydrates do not contain fatty acids that are broken down into ketones.

The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion?

HCO 3 value is 50 mEq/L (50 mmol/L). The HCO 3 value is elevated. The urinary system compensates by retaining H + ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO 3 value is 21 to 28 mEq/L (21 to 28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO 2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO 2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis [1] [2] the PCO 2 level may be increased, it is the increased HCO 3 level that indicates compensation. A K + level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply.

Headache Irritability Restlessness Headache is a symptom of cerebral hypoxia associated with early respiratory acidosis [1] [2]. Irritability is a sign of cerebral hypoxia associated with early respiratory acidosis. Restlessness is a sign of cerebral hypoxia associated with early respiratory acidosis. Hypotension, not hypertension, is a key feature of acidosis. Lightheadedness is a symptom of respiratory alkalosis, not acidosis.

A nurse in the emergency department is working triage. Which patient assessment findings would indicate immediate care is required?

Inability to swallow and move the left arm Correct Inability to swallow and move the left arm suggests the patient is experiencing a stroke. A CT scan is indicated within 25 minutes of arrival to determine ischemic versus hemorrhagic origin, which will delineate available treatments. The warm, edematous, reddened and painful calf suggests deep vein thrombosis. Although not an immediate threat, there is a risk of pulmonary emboli. A shortened and externally rotated leg suggests a hip fracture. A patient with yellow sputum and pain with deep inspiration suggest a pneumonia that may require hospitalization or could be treated as an outpatient.

The nurse is teaching the residents of an independent living facility about preventing skin infections and infestations. What should be included in the teaching?

Inspect skin for changes when bathing with mild soap. Correct Persons living in independent living facilities are usually older, which means their skin does not need cleaning with hot water and vigorous scrubbing or as often as a younger person. Mild soap (e.g., Ivory) should be used to avoid loss of protection from neutralization of the skin's surface. The skin should be inspected for changes with bathing. Cool compresses are used with ringworm or stings for the antiinflammatory effect. Oral antibiotics are used for Lyme disease from ticks. Antiviral agents are used for viral infections but not to prevent outbreaks.

What is the priority nursing action in the care of a young child with severe diarrhea?

Maintaining fluid and electrolyte balance Maintaining fluid and electrolyte balance is the priority intervention to reduce risk of harm to the patient. Measuring daily urine output is important as a means of checking kidney function, but maintaining overall fluid and electrolyte balance is the priority. If a child is severely dehydrated, urine output needs to be checked more often than daily. Nutrition is not a priority above fluid and electrolyte balance at this time. Although important, skin integrity is not the priority.

A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect?

No pain, waxy white skin, and no blanching with pressure Correct With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

The patient with a stage IV pressure ulcer on the coccyx will need a skin graft to close the wound. Which postoperative care should the nurse expect to use to facilitate healing?

No straining of the grafted site Correct Straining or stretching of the grafted site must be avoided to allow the graft to be vascularized and fixed to the new site for healing. The wound may or may not be exposed to air depending on the type of graft, and the donor site will be covered with a protective dressing to prevent further damage. Soft tissue expansion and pressure dressings will not be used after this wound's skin graft.

A patient informs the nurse of experiencing syncope. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup?

Preparing to assist with a head-up tilt-test In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup after episodes of syncope. IV β-blockers are not indicated, although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient's syncope at this time.

The nurse observes ventricular tachycardia (VT) on the patient's monitor. What evaluation made by the nurse led to this interpretation?

Rate 200 beats/min; P wave not visible Correct VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.

Continue to monitor vital signs, cardiac rhythm, and neurologic and pulmonary status hourly or more frequently, as indicated by the patient's condition or per the organization's practice, until the patient is admitted or discharged home. Why?

Rationale: Transient hypotension may occur after synchronized cardioversion.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation?

Reddening of the skin Correct The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

In a patient admitted with cellulitis of the left foot, which clinical manifestation would the nurse expect to find on assessment of the left foot?

Redness and swelling Correct Cellulitis is a diffuse, acute inflammation of the skin. It is characterized by redness, swelling, heat, and tenderness in the affected area. These changes accompany the processes of inflammation and infection.

A client is diagnosed with diabetic ketoacidosis. Which insulin should the nurse expect the health care provider to prescribe?

Regular insulin Regular insulin is rapid acting and should be used for diabetic coma. Insulin glargine is long-acting insulin, which is not indicated in an emergency. NPH insulin is intermediate-acting insulin; it is not indicated for use in an emergency. Inhaled insulin has not been approved for management of diabetic ketoacidosis.

A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation?

Respiratory alkalosis Increased rate and depth of breathing result in excessive elimination of CO 2, and respiratory alkalosis [1] [2] can result. Tetany is associated with hypocalcemia. With hyperventilation, CO 2 levels will be decreased (hypocapnia), not elevated. Metabolic acidosis results from excess hydrogen ions caused by a metabolic problem, not a respiratory problem.

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn?

Skin is shiny and red with clear, fluid-filled blisters. Correct Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what?

Sodium Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.

A nurse is administering a histamine H 2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent?

Stress ulcer An ulcer of the upper gastrointestinal tract is related to excessive secretion of stress-related hormones, which increases hydrochloric acid production. Histamine H 2 antagonists decrease acid secretion. Colitis is not a complication of burns. Gastritis is not a complication of burns. Metabolic acidosis is not a complication of burns unless hypermetabolism or renal failure occurs; metabolic acidosis is not treated with H 2 antagonists.

A patient admitted with heart failure is also diagnosed with herpes zoster and draining vesicles. Which action, if observed by the nurse, would require additional teaching for that individual?

The dietitian wears a mask when entering the patient's room. Correct Herpes zoster, commonly known as shingles, is spread by contact with fluid draining from the vesicles (not by coughing, sneezing, or casual contact). Shingles is not contagious before the vesicles appear or after the vesicles have crusted over. The risk of a person with shingles spreading the virus is low if the rash is covered. Wearing a mask would not prevent the spread of infection. Until the rash develops crusts, the patient should not have contact with an immunocompromised person (e.g., a person taking prednisone). Frequent hand washing helps to prevent the spread of varicella zoster virus.

An infant who has had diarrhea for 3 days is admitted in a lethargic state and is found to be breathing rapidly. The parent states that the baby has been taking formula, although not as much as usual, and cannot understand the sudden change. What explanation should the nurse give the parent?

The extracellular fluid requirement per unit of body weight is greater in infants than in adults.

The nurse informs the patient that she must wear intermittent sequential compression stockings after a surgical procedure. What is an appropriate rationale for nurse to give to the patient for the use of the device?

The socks provide compression of the veins to keep the blood moving back to the heart. Correct

The nurse obtains a 6-second rhythm strip and charts the following analysis:

Third-degree heart block Third-degree heart block represents a loss of communication between the atrium and ventricles from atrioventricular node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction). Whereas the atria are beating totally on their own at 70 beats/min, the ventricles are pacing themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing. Premature ventricular contractions are the early occurrence of a wide, distorted QRS complex.

A patient presents to the emergency department with reports of chest pain for 3 hours. What component of his blood work is most clearly indicative of a myocardial infarction (MI)?

Troponin

The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation (select all that apply.)?

Urine output is 46 mL/hr. Correct Heart rate is 94 beats/min. Correct Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030.

For patients with ______________________________ of greater than 48 hours' duration, treatment options include rate control with medication, consultation with the patient's primary care practitioner, or delayed cardioversion after anticoagulation therapy

atrial fibrillation

Be sure to correct __________________, which may predispose the patient to postshock arrhythmias such as ventricular fibrillation.8

hypokalemia

examples of a yellow tag

stable upper extrimity fracture must have pulse soft tissue injury , facial wounds that do not obstruct airway, gi obstruction, eye injuries, nerve injuries

red tag examples

sucking chest wound, airway obstruction, shock, hemothorax, pneomothorax, long bone fractures, burn less than 60% of body

examples of a green tag

P-hen

The nurse is teaching a group of students about assessing for respiratory system manifestations of alkalosis as a nursing priority. Which statement made by the student nurse indicates the need for further teaching? Select all that apply.

"I should assess for low blood pressure." "I should assess for increased digitalis toxicity." "I should assess for a decreased rate of ventilation in respiratory alkalosis." The nurse should assess for low blood pressure and increased digitalis toxicity as cardiovascular manifestations of alkalosis, not respiratory manifestation. The nurse should assess for increased rate of ventilation in respiratory alkalosis. The nurse should assess for increased depth of ventilation in respiratory alkalosis. It is imperative that the nurse check for decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis.

The nurse is teaching a client with a furuncle about preventing the spread of infection. Which statement made by the client indicates effective learning?

"I will use an antibacterial soap while bathing." Skin care with proper cleansing may help to prevent the spread of infection; therefore the client should use an antibacterial soap while bathing. Occlusive dressings promote microorganism growth due to the presence of excessive moisture. Applying warm compresses to a furuncle helps in providing comfort. Removal of crusts before applying the drug helps in easy absorption of medication.

The nurse is teaching a group of students about the manifestation of alkalosis in the central nervous system. Which statements by a student nurse are accurate? Select all that apply.

"The client's Trousseau sign would be positive." "The client would be suffering from paresthesias." "The client would show signs of anxiety and irritability." If clients suffer from the alkalosis, the manifestation in the nervous system would involve paresthesias. The client will also have a positive Trousseau sign and have anxiety and irritability. The Chvostek sign would also be positive, not negative. The client would show signs of anxiety and irritability. The central nervous system should have increased activity with alkalosis, not decreased.

An adolescent child who has sustained full-thickness burns is to undergo skin grafting. The nurse explains to the child's parents that the child will need what for permanent grafts?

Autografts Autografts consist of tissue from the individual's own body, meaning that the chance of rejection is minimal. Steroids are not part of the therapy for skin grafts. Homografts consist of tissue from genetically different members of the same species, usually a cadaver; they are used as temporary grafts. Immunosuppressive drugs are not part of the therapy for skin grafts.

5. For which patient should the risk for complications of synchronized cardioversion be seriously considered?

B. A patient with a low potassium level Rationale: Hypokalemia may predispose a patient to postshock arrhythmias. A therapeutic digoxin level is desired; a toxic level increases the patient's risk for ventricular arrhythmias after cardioversion. A rapid ventricular rate and low blood pressure are indications to perform synchronized cardioversion.

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed?

Diuresis occurs and hematocrit decreases. Correct In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

A client is scheduled to receive irradiation to the chest wall after a tumor was removed from the client's lung. Which information will the nurse emphasize when teaching skin care to the client?

Keeping the skin dry to protect it from excoriation The skin is the first line of defense; keeping it dry and safe from injury promotes skin integrity. Massage is traumatic, because irradiated skin is fragile and subject to blistering and sloughing. The skin should be free of emollients, because they can be irritating. Irradiated skin is fragile; washing the area frequently can be irritating.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question?

Lactated Ringer's solution at 25 mL/hr Correct Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's solution at 2 to 4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

A nurse teaches the emergency department staff about their roles during a mass casualty incident. Which primary responsibility is expected of all licensed and unlicensed health care staff?

Learn the hospital emergency response plan. Correct All health care providers must be prepared for a mass casualty incident. The priority responsibility is to know the agency's emergency response plan.

Which assessment finding in a client signifies a mild form of hypocalcemia?

Numbness around the mouth A numbness or tingling sensation around the mouth or in the hands and feet indicates mild-to-moderate hypocalcemia. Seizures, hand spasms, and severe muscle cramps are associated with severe hypocalcemia.

A client arrives in the emergency department with epigastric pain and prolonged vomiting. Assessment findings include rapid and shallow respirations, dry and flushed skin, weakness, and lethargy. Which is the primary nursing concern?

Metabolic alkalosis Prolonged vomiting results in fluid loss and acid (hydrochloric) loss; the client's adaptations reflect dehydration and metabolic alkalosis. Although it is important to address the client's pain, the fluid and electrolyte/acid/base imbalance must be addressed first because this imbalance can be life threatening. Although risk for injury is a potential problem, the priority is the fluid and electrolyte/acid/base problem. The ineffective breathing pattern most likely is caused by the metabolic alkalosis; the fluid and electrolyte/acid/base imbalance is a higher priority and must be addressed first.

The nurse would assess a patient admitted with cellulitis for what localized manifestation?

Pain Pain, redness, heat, and swelling are all localized manifestation of cellulitis. Fever, chills, and malaise are generalized, systemic manifestations of inflammation and infection.

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury (select all that apply.)?

Singed nasal hair Correct Generalized pallor Correct Painful swallowing Correct History of being involved in a large fire Correct Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.

The patient has atrial fibrillation with a rapid ventricular response. What electrical treatment option does the nurse prepare the patient for?

Synchronized cardioversion Correct Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death, have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first?

Take vital signs and notify the primary healthcare provider. Vital signs monitor the cardiopulmonary status; the primary healthcare provider must treat this hyperkalemia [1] [2] to prevent cardiac dysrhythmias. The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. Although obtaining an ECG strip is appropriate, obtaining an antiarrhythmic is premature; vital signs and medical attention is needed first.

The nurse knows the ventricular contractions are directly stimulated by which anatomic feature of the heart?

The Purkinje fibers move the electrical impulse or action potential through the walls of both ventricles triggering synchronized right and left ventricular contraction. The sinoatrial (SA) node initiates the electrical impulse that results in atrial contraction. The atrioventricular (AV) node receives the electrical impulse through internodal pathways. The bundle of His receives the impulse from the AV node.

A patient is admitted with severe dyspnea, a history of heart failure, and chronic obstructive lung disease. Which diagnostic study would the nurse expect to be elevated if the cause of dyspnea was cardiac related?

b-type natriuretic peptide (BNP) Correct Elevation of BNP indicates the presence of heart failure. Elevations help to distinguish cardiac versus respiratory causes of dyspnea. Elevated potassium, homocysteine, or HDL levels may indicate increased risk for cardiovascular disorders but do not indicate that cardiac disease is present.

A patient has been diagnosed with tinea unguium (onychomycosis) under the nails but does not like the oral antifungal medication. What is the best alternate treatment the nurse should describe for her?

Nail avulsion CorrectNail avulsion is the best alternate treatment to the oral antifungal medication. Antifungal cream is minimally effective. Thinning fingernails is not needed if the tinea unguium is under her toenails. Soaking the nails will not be helpful.

Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow?

Patients should be routinely screened for family and IPV. Correct In the emergency department, the nurse needs to screen for family and IPV. Routine screening for this risk factor is required. Such assessment should not be limited to female, high-risk, or young patients, and evidence need not be present to screen for the problem.

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the electrocardiogram (ECG)?

The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers Correct

A patient develops third-degree heart block and reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing?

"The device delivers a current through your skin that can be uncomfortable." Correct Before initiating transcutaneous pacing therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is delivered through pacing pads adhered to the skin.

Which patient should the nurse prepare to transfer to a regional burn center?

A 53-yr-old patient with a chemical burn to the anterior chest and neck Correct The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma. Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.

When looking at the electrocardiogram (ECG) of the patient, the nurse knows that the QRS complex recorded on the ECG represents which part of the heart's beat?

Depolarization from atrioventricular (AV) node throughout ventricles Correct The QRS recorded on the ECG represents depolarization from the AV node throughout the ventricles. The P wave represents depolarization of the atria. The T wave represents repolarization of the ventricles. The interval between the PR and QRS represents the length of time it takes for the impulse to travel from the atria to the ventricles.

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care (select all that apply.)?

Escharotomy Correct IV and oral pain medications Correct Daily cleansing and debridement Correct Application of topical antimicrobial agent Correct An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L (5.4 mmol/L). What would the nurse expect to see on the ECG tracing monitor?

Peaked T waves and widened QRS complexes Potassium is the principal intracellular cation, and during ketoacidosis it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic diuresis; overstimulation of the cardiac muscle results. The T wave is depressed in hypokalemia. Initially, the QT segment is short, and as the potassium level rises, the QRS complex widens. P waves are abnormal because the PR interval may be prolonged and the P wave may be lost; however, the T wave is peaked, not depressed. The ST segment becomes depressed. The PR interval is prolonged, and the P wave may be lost. QRS complexes and thus T waves become irregular, and the rate does not necessarily change.