Semester 4 - Exam 4

Which patient positioning strategies would the nurse use while caring for a patient with acute respiratory distress syndrome (ARDS)? Select all that apply. -Kinetic therapy -Prone positioning -Supine positioning -Trendelenburg position -Continuous lateral rotation therapy

-Kinetic therapy -Prone positioning -Continuous lateral rotation therapy

A client with burns over 35% of the body reports chilling. Which action will the nurse take to promote client comfort? -Limit room drafts. -Place a sterile top sheet over the client. -Decrease the room humidity to less than 10%. -Maintain an 80°F (26.7°C) room temperature.

-Limit room drafts.

The nurse is caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the priority during the emergent phase of this injury? -Preventing pain -Managing leukopenia -Preventing infection -Managing fluid loss

-Managing fluid loss

A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? -Monitor for kidney failure. -Monitor psychosocial status. -Monitor for signs of bleeding. -Have heparin sodium available.

-Monitor for signs of bleeding. Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication.

Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct. -Monitoring vital signs -Cutting off the clothing -Inserting a urinary catheter -Removing the client's jewelry -Establishing an intravenous line

-Monitoring vital signs -Cutting off the clothing -Inserting a urinary catheter -Removing the client's jewelry -Establishing an intravenous line

How would the nurse classify burns that are painful, red to white, and edematous? -Eschar -Deep full-thickness burns -Deep partial-thickness burns -Superficial partial-thickness burns

-Deep partial-thickness burns

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? -A low respiratory rate -Diminished breath sounds -The presence of a barrel chest -A sucking sound at the site of injury

-Diminished breath sounds This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema.

A patient is prescribed warfarin following a deep venous thrombosis and pulmonary embolism. Which information would the nurse include in the teaching plan? Select all that apply. -Eliminate green vegetables from the diet. -Do not take ibuprofen or aspirin unless prescribed. -Use a soft toothbrush and observe the gums for bleeding. -Wear a bracelet that identifies that the patient is taking an anticoagulant. -Blood coagulation testing is needed only for the first four to six weeks of therapy.

-Do not take ibuprofen or aspirin unless prescribed. -Use a soft toothbrush and observe the gums for bleeding. -Wear a bracelet that identifies that the patient is taking an anticoagulant.

Which action would the nurse perform immediately for a patient with acute pancreatitis who develops acute respiratory distress syndrome (ARDS)? -Infuse normal saline. -Give chest compressions. -Provide ventilatory support. -Schedule a portable chest x-ray.

-Provide ventilatory support.

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? -Tea -Cola -Coffee -Raspberry juice

-Raspberry juice A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? -Remove the dressing. -Reinforce the dressing. -Call the primary health care provider (PHCP). -Measure oxygen saturation by oximetry.

-Remove the dressing. Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse should remove the dressing immediately, allowing air to escape.

Which specific emergency burn management would be appropriate for a client hospitalized with burns caused by flames? -Removing all metal objects -Helping the client bathe or shower -Initiating cardiopulmonary resuscitation -Administering tetanus toxoid for prophylaxis

-Removing all metal objects

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? -Respiratory acidosis from inadequate ventilation -Respiratory alkalosis from anxiety and hyperventilation -Metabolic acidosis from calcium loss due to broken bones -Metabolic alkalosis from taking analgesics containing base products

-Respiratory acidosis from inadequate ventilation Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis.

Which arterial blood gas finding is associated with a patient experiencing early shock? -Metabolic acidosis -Metabolic alkalosis -Respiratory acidosis -Respiratory alkalosis

-Respiratory alkalosis

For the patient on the intensive care unit (ICU), which problem would the nurse associate with a series of increased central venous pressure (CVP) readings? -Cardiogenic shock -Circulatory failure -Left ventricular failure -Right ventricular failure

-Right ventricular failure

Which is a primary clinical manifestation of flail chest in an unconscious patient? -Cyanosis -Shallow respirations -Neck vein distention -Decreased heart rate

-Shallow respirations

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68 mm Hg. The nurse minimally suspects which stage of shock based on this data? -Stage 1 -Stage 2 -Stage 3 -Stage 4

-Stage 2 Stage 1 is characterized by restlessness, increased heart rate, cool and pale skin, and agitation. Stage 2 is characterized by a cardiac output that is less than 4 to 6 liters per minute, systolic blood pressure less than 100 mm Hg. Stage 3 is characterized by edema, excessively low blood pressure, dysrhythmias, and weak and thready pulses. Stage 4 is characterized as unresponsiveness to vasopressors, profound hypotension, slowed heart rate, and multiple organ failure. Most often, the client will not survive.

The nurse is teaching a student nurse about pulmonary embolism. Which response by the student indicates to the nurse teaching was effective? -"A clot in the iliac vein may lead to a potentially lethal pulmonary emboli." -"A clot in the portal vein may lead to a potentially lethal pulmonary emboli." -"A clot in the jugular vein may lead to a potentially lethal pulmonary emboli." -"A clot in the lumbar vein may lead to a potentially lethal pulmonary emboli."

-"A clot in the iliac vein may lead to a potentially lethal pulmonary emboli."

A client is admitted to the emergency department with a diagnosis of myocardial infarction (MI). The primary health care provider (PHCP) prescribes the administration of alteplase. The registered nurse (RN) preceptor is orienting a new RN in the use of this medication. Which statement by the new RN indicates that teaching has been effective? -"Administer the medication within 4 to 6 hours after onset of chest pain." -"Administer the medication concurrently with the administration of heparin." -"Administer the medication with the administration solution set protected from light." -"Administer the medication after the results of all laboratory tests have been received."

-"Administer the medication within 4 to 6 hours after onset of chest pain."

Which instruction does the nurse give to a patient when removing the patient's chest tube? -"Lie on the side that is the opposite of the chest tube." -"Take some deep breaths throughout the procedure." -"Bear down while the tube is being removed." -"Drink a large amount of water just before the procedure."

-"Bear down while the tube is being removed."

The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? -"I need to start exercising more to improve my health." -"I will be sure to keep my appointment with the cardiologist." -"I don't have anyone to help me with doing heavy housework at home." -"I think I have a good understanding of what all my medications are for."

-"I don't have anyone to help me with doing heavy housework at home." To ensure the best outcome, clients should be able to comply with instructions related to activity, diet, medications, and follow-up health care on discharge from the hospital after an MI. All of the options except the correct one indicate that the client will be successful in these areas.

Which statement regarding interventions for clients with inhalation burns shows a nurse needs further education? -"I would administer intravenous analgesia." -"I would prepare for an endotracheal intubation." -"I would anticipate the need for a fiberoptic bronchoscopy." -"I would immediately calculate the burned surface area with the rule of nines."

-"I would immediately calculate the burned surface area with the rule of nines."

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate? -"Strapping is useful only if the ribs are fractured in several places at once." -"That's a good idea. I'll ask the primary health care provider for a prescription for the needed supplies." -"That isn't done because people often would develop pneumonia from the constricting effect on the lungs." -"That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store."

-"That isn't done because people often would develop pneumonia from the constricting effect on the lungs."

Which classification would the nurse use to describe burns that are painful, mottled red, weeping, and edematous? -Eschar -Full-thickness -Deep partial-thickness -Superficial partial-thickness

-Deep partial-thickness

At which time would the nurse plan to administer morphine 2 mg by mouth every 2 hours as needed to a client who has burns on 55% of the body surface and requires dressing changes? -15 minutes before the dressing change -60 minutes before the dressing change -Along with a stool softener each time it is administered -Only if the client rates pain between 8 and 10 on the pain scale

-60 minutes before the dressing change

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? -Muffled heart sounds -Client reports dyspnea -A rise in blood pressure -Jugular venous distention

-A rise in blood pressure Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade.

For which reasons are abdominal aortic aneurysms (AAAs) often difficult to diagnose in the early phase? Select all that apply. -AAAs are often asymptomatic. -AAAs often go undetected during routine exams. -AAAs may mimic the symptoms of other diseases. -Highly specialized equipment is needed to diagnose AAAs. -Physical findings related to AAAs may be more difficult to detect in obese individuals.

-AAAs are often asymptomatic. -AAAs may mimic the symptoms of other diseases. -Physical findings related to AAAs may be more difficult to detect in obese individuals.

When a patient admitted with respiratory failure has a low central venous pressure (CVP), which action prescribed by the health care provider will the nurse question? -Administer furosemide 20 mg per hour IV. -Infuse normal saline 75 mL per hour IV. -Give methylprednisolone 125 mg IV. -Administer lorazepam 1 mg IV.

-Administer furosemide 20 mg per hour IV.

Which actions would the nurse take to safely administer dobutamine to a patient with cardiogenic shock? Select all that apply. -Use a glass bottle for infusion. -Administer through a central line. -Monitor heart rate and BP. -Stop infusion if tachydysrhythmias develop. -Always administer with sodium bicarbonate.

-Administer through a central line. -Monitor heart rate and BP. -Stop infusion if tachydysrhythmias develop.

Which nursing interventions would the nurse perform when administering dopamine to a patient experiencing cardiogenic shock? Select all that apply. -Administer via a central line. -Monitor for tachydysrhythmias. -Administer with sodium bicarbonate. -Monitor for peripheral vasoconstriction. -Monitor for pulmonary edema.

-Administer via a central line. -Monitor for tachydysrhythmias. -Monitor for peripheral vasoconstriction.

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client? -Administration of digoxin -Administration of whole blood -Administration of intravenous fluids -Administration of packed red blood cells

-Administration of digoxin The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction.

A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which initial physiological change will the nurse expect? -An increase in blood volume -An increase in serum potassium -A decrease in capillary permeability -A decrease in urinary specific gravity

-An increase in serum potassium

The nurse assesses a patient with cardiogenic shock and expects which findings? Select all that apply. -Anxiety -Tachycardia -Hypertension -Decreased urine output -Weak peripheral pulses

-Anxiety -Tachycardia -Decreased urine output -Weak peripheral pulses

Which interventions would the nurse expect to include in the nutritional plan of care for a patient with severe burns who has been intubated? Select all that apply. -Assess respiratory rate every two hours. -Assess bowel sounds every eight hours. -Begin large amounts of feeding within the first six hours. -Begin early enteral feeding with smaller-bore tubes. -Begin the feedings slowly at a rate of 20 to 40 mL/hr.

-Assess bowel sounds every eight hours. -Begin early enteral feeding with smaller-bore tubes. -Begin the feedings slowly at a rate of 20 to 40 mL/hr.

Which actions would the nurse perform for a patient who just sustained partial-thickness burns on the hands and chest caused by a fire? Select all that apply. -Assess for inhalation injury. -Provide 100% humidified oxygen. -Avoid dry dressings on the wounds. -Assess airway, breathing, and circulation. -Avoid mechanical ventilation for 24 hours.

-Assess for inhalation injury. -Provide 100% humidified oxygen. -Assess airway, breathing, and circulation.

In which order would the nurse take these actions when a client arrives in the emergency department with burns of the chest? -Insert an intravenous (IV) catheter. -Calculate the extent of the client's burns. -Cover the client with a warm blanket. -Assess the client's respiratory rate.

-Assess the client's respiratory rate. -Insert an intravenous (IV) catheter. -Cover the client with a warm blanket. -Calculate the extent of the client's burns.

Which nursing interventions would be utilized in patients with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), specific to the hematologic dysfunction commonly experienced by patients? Select all that apply. -Avoiding multiple venipunctures -Minimizing IM injections -Infusing insulin and glucose continuously -Ensuring continuous echocardiographic monitoring -Providing positive end-expiratory pressure ventilation

-Avoiding multiple venipunctures -Minimizing IM injections

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; PO2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition would the nurse suspect the client has based on these findings? -Azotemia -Hypokalemia -Metabolic alkalosis -Respiratory alkalosis

-Azotemia

Which initial interventions would the nurse perform as a part of emergency burn management for a patient who has sustained full-thickness burns covering more than 20% of the total body surface area? Select all that apply. -Begin fluid replacement. -Avoid supplemental oxygen. -Cover burned areas with dry dressings. -Lower the burned limbs below the heart level. -Establish IV access with two large-bore catheters.

-Begin fluid replacement. -Cover burned areas with dry dressings. -Establish IV access with two large-bore catheters.

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply. One, some, or all responses may be correct. -Bradycardia -Hypotension -Spastic paralysis -Urinary retention -Increased pulse pressure

-Bradycardia -Hypotension -Urinary retention

Which assessment findings would the nurse expect to see in a client admitted to the hospital because of electrical burns? Select all that apply. One, some, or all responses may be correct. -Coughing -Burn odor -Smoky breath -Leathery skin -Cardiac arrest

-Burn odor -Leathery skin -Cardiac arrest

A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take? -Call the primary health care provider immediately. -Document these findings, which are expected. -Re-evaluate the neurovascular status in 1 hour. -Increase the rate of the intravenous nitroglycerin infusion.

-Call the primary health care provider immediately. The nursing interventions for the client with an intra-aortic balloon pump are the same as for any client who has had cardiovascular surgery. The peripheral circulation to the affected limb is monitored for signs of occlusion, such as coolness, mottling, pain, tingling, and decreased or absent distal pulse. Adverse changes are reported immediately.

Which condition places a patient at risk for obstructive shock? -Pneumonia -Severe burn -Cardiac tamponade -Hypersensitivity to a vaccine

-Cardiac tamponade

Which conditions could be the possible causes of obstructive shock? Select all that apply. -Spinal cord injury -Cardiac tamponade -Tension pneumothorax -Hypersensitivity to antibiotics -Superior vena cava syndrome

-Cardiac tamponade -Tension pneumothorax -Superior vena cava syndrome

A client is brought to the emergency department complaining of substernal chest pain. To distinguish between angina and myocardial infarction, the nurse assesses for which characteristics of angina? Select all that apply. -Chest pain that resolves with rest -Chest pain requiring an opioid for relief -Chest pain that is relieved by nitroglycerin -Chest pain that lasts longer than 30 minutes -Chest pain that is usually precipitated by exertion

-Chest pain that resolves with rest -Chest pain that is relieved by nitroglycerin -Chest pain that is usually precipitated by exertion

Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock? -Urine output 1000 mL in 8 hours -Oral temperature 101°F (38.3°C) -Client report of feeling very thirsty -Bounding radial and femoral pulses

-Client report of feeling very thirsty

For the nurse wanting to transfer to the intensive care unit (ICU), which skill would the nurse need to have to be an effective critical care nurse? -Planning -Evaluation -Assessment -Collaboration

-Collaboration

The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The primary health care provider states that because of fluid in the alveoli, surfactant production is falling. The nurse anticipates that insufficient surfactant will cause which effect? -Atelectasis and viral infection -Bronchoconstriction and stridor -Collapse of alveoli and decreased compliance -Decreased ciliary action and retained secretions

-Collapse of alveoli and decreased compliance

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? -Slow heart rate -Cool skin temperature -Bounding radial pulses -Increased urine output

-Cool skin temperature

Which hormone level would the nurse expect to be elevated in the laboratory report of a patient with severe burns? -Cortisol -Oxytocin -Aldosterone -Antidiuretic hormone

-Cortisol Cortisol is a glucocorticoid that protects the body from stress; it is also called a stress hormone. Cortisol helps to maintain vascular integrity and fluid volume; cortisol levels are increased in patients with burns, infections, fevers, and acute anxiety.

Which early clinical manifestations of acute respiratory distress syndrome (ARDS) will the nurse monitor for when caring for a patient admitted with sepsis? Select all that apply. -Oliguria -Respiratory acidosis -Cough and restlessness -Dyspnea and tachypnea -Adventitious lung sounds

-Cough and restlessness -Dyspnea and tachypnea -Adventitious lung sounds

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? -Stridor -Crackles -Scattered rhonchi -Diminished breath sounds

-Crackles Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles.

Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply. -Bradypnea -Flattened neck veins -Decreased cardiac output -Hyperresonance to percussion -Tracheal deviation to the opposite side

-Decreased cardiac output -Hyperresonance to percussion -Tracheal deviation to the opposite side

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. -Excessive bubbling in the water seal chamber -Vigorous bubbling in the suction control chamber -Drainage system maintained below the client's chest -50 mL of drainage in the drainage collection chamber -Occlusive dressing in place over the chest tube insertion site -Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

-Drainage system maintained below the client's chest -50 mL of drainage in the drainage collection chamber -Occlusive dressing in place over the chest tube insertion site -Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

Which actions will the nurse take as part of the ventilator bundle when caring for a patient with acute respiratory failure who requires mechanical ventilation? Select all that apply. -Elevate head of bed to 30-45 degrees. -Keep patient sedated for comfort. -Administer proton pump inhibitors. -Give injectable anticoagulant medications. -Assist with maintaining patient in prone position.

-Elevate head of bed to 30-45 degrees. -Administer proton pump inhibitors. -Give injectable anticoagulant medications.

The release of platelet-activating factors in patients who have sepsis triggers which response? -Third spacing -Formation of microthrombi -Increased capillary permeability -Decreased production of cytokines

-Formation of microthrombi

Which actions will the nurse take to decrease risk for ventilator-associated pneumonia (VAP) in a patient receiving mechanical ventilation for acute respiratory distress syndrome? Select all that apply. -Frequent handwashing -Monitoring central venous pressure -Avoiding overuse of sedative drugs -Frequent mouth care and oral hygiene -Sterile technique for endotracheal suctioning

-Frequent handwashing -Avoiding overuse of sedative drugs -Frequent mouth care and oral hygiene -Sterile technique for endotracheal suctioning

A nurse is caring for a patient with a pulmonary embolism who is on warfarin therapy. Which parameter would the nurse monitor in this patient? -Hematomas -Polycythemia -B-type natriuretic peptide -White blood cell differentials

-Hematomas

The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow? -High caloric intake, liberal potassium intake, and 3 g protein/kg per day -High caloric intake, restricted potassium intake, and 1 g protein/kg per day -Moderate caloric intake, liberal potassium intake, and 3 g protein/kg per day -Moderate caloric intake, restricted potassium intake, and 1 g protein/kg per day

-High caloric intake, liberal potassium intake, and 3 g protein/kg per day

The nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction? -Deep breathing -Hoarse quality to the voice -Pink-tinged, frothy sputum -Rapid abdominal breathing

-Hoarse quality to the voice

Which clinical manifestation suggests sepsis? -Hyperglycemia in the absence of diabetes -Sudden diuresis unrelated to drug therapy -Respiratory rate of seven breaths per minute -Bradycardia with sudden increase in BP

-Hyperglycemia in the absence of diabetes

A patient experiences a sucking chest wound as a result of a surgical thoracotomy. Which type of pneumothorax does the nurse suspect? -Tension -Iatrogenic -Traumatic -Spontaneous

-Iatrogenic

A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first? -Increase the rate of O2 flow -Obtain arterial blood gas results -Insert an indwelling urinary catheter -Increase the rate of intravenous (IV) fluids

-Increase the rate of intravenous (IV) fluids

Which laboratory finding would the nurse expect to see in a patient with cardiogenic shock? -Decreased liver enzymes -Increased white blood cells -Decreased red blood cells -Increased blood urea nitrogen (BUN)

-Increased blood urea nitrogen (BUN)

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?-Bilateral wheezing -Inspiratory crackles -Intercostal retractions -Increased respiratory rate

-Increased respiratory rate The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body.

The nurse provides which information about the water-seal chamber on a chest drainage unit (CDU) when educating a group of nursing students? -It contains 2 cm of water. -It acts as a two-way valve. -It receives fluid and air from the pleural space. -It applies suction to the chest drainage system.

-It contains 2 cm of water.

Which factors would the nurse consider regarding the use of antibiotics for a patient with burns? Select all that apply. -It is essential to check the patient for allergies to sulfa. -Systemic antibiotics are routinely used to control burn wound flora. -Silver-impregnated dressings can be left in place from 3 to 14 days. -Silver sulfadiazine or mafenide acetate creams should never be used. -Topical antimicrobial agents may be applied after the wound cleansing.

-It is essential to check the patient for allergies to sulfa. -Silver-impregnated dressings can be left in place from 3 to 14 days. -Topical antimicrobial agents may be applied after the wound cleansing.

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? -Heart failure -Atrial fibrillation -Myocardial infarction -Ventricular tachycardia

-Myocardial infarction Cardiac troponin T or cardiac troponin I have been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction.

A client undergoes a subtotal gastrectomy. After surgery the client begins to hemorrhage. Which clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. One, some, or all responses may be correct. -Oliguria -Bradypnea -Diaphoresis -Tachycardia -Hypertension

-Oliguria -Diaphoresis -Tachycardia

A client has a colon resection with an anastomosis. Which assessments by the nurse support a suspicion of impending shock? Select all that apply. One, some, or all responses may be correct. -Oliguria -Lethargy -Irritability -Hypotension -Slurred speech

-Oliguria -Irritability -Hypotension

Which finding by the nurse is the best indicator that measures to improve oxygenation in a patient on mechanical ventilation for acute respiratory distress syndrome have been effective? -Oxygen saturation 90% to 93% -Decreased rhonchi and crackles -Patient report of improving dyspnea -Stable heart rate and BP

-Oxygen saturation 90% to 93%

When a client with hypovolemic shock has a hematocrit value of 25%, which fluid therapy will the nurse prepare to infuse? -Lactated Ringer solution -Human serum albumin 5% -Packed red blood cells -High molecular weight dextran

-Packed red blood cells

Which clinical findings would the nurse expect when assessing a client who has cardiogenic shock? Select all that apply. One, some, or all responses may be correct. -Pallor -Agitation -Tachycardia -Narrow pulse pressure -Decreased respirations

-Pallor -Agitation -Tachycardia -Narrow pulse pressure

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall? -Partial-thickness burns require grafting before they can heal. -Partial-thickness burns are often painful, reddened, and have blisters. -Partial-thickness burns cause destruction of both the epidermis and dermis. -Partial-thickness burns often take months of extensive treatment before healing.

-Partial-thickness burns are often painful, reddened, and have blisters.

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? -Decreased rate of glomerular filtration -Excessive blood loss through the burned tissues -Plasma proteins moving out of the intravascular compartment -Sodium retention occurring as a result of the aldosterone mechanism

-Plasma proteins moving out of the intravascular compartment

Which interprofessional intervention will the nurse anticipate for a patient with intrapulmonary shunt due to acute respiratory distress syndrome (ARDS)? -Positive pressure ventilation -Avoidance of high FIO2 levels -Actions to keep PaCO2 less than 60 mm Hg -Use of high tidal volumes with mechanical ventilation

-Positive pressure ventilation

When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? Select all that apply. -Pregnancy -Pneumonia -Cancer -Oral contraceptive use -Hormone therapy

-Pregnancy -Cancer -Oral contraceptive use -Hormone therapy

A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions are a priority? Select all that apply. -Stop the infusion. -Raise the head of the bed. -Administer protamine sulfate. -Administer diphenhydramine. -Call for the Rapid Response Team (RRT).

-Stop the infusion. -Administer diphenhydramine. -Call for the Rapid Response Team (RRT). The client is experiencing an anaphylactic reaction. Therefore, the priority action is to stop the infusion and notify the RRT. The client may be treated with antihistamines.. Raising the head of the bed would not be helpful, as that may exacerbate the hypotension. Protamine sulfate is the antidote for heparin, so it is not useful for a client receiving alteplase.

The nurse reviews the treatment plan of a patient with acute respiratory distress syndrome (ARDS) on mechanical ventilation. A ventilator bundle protocol has been prescribed that includes which components? Select all that apply. -Stress ulcer prophylaxis -Extubation readiness assessment -Elevation of the head of the bed 30 to 45 degrees -Venous thromboembolism prophylaxis -Oral care daily with chlorhexidine (0.12%) solution -Prophylactic antibiotic therapy

-Stress ulcer prophylaxis -Extubation readiness assessment -Elevation of the head of the bed 30 to 45 degrees -Venous thromboembolism prophylaxis -Oral care daily with chlorhexidine (0.12%) solution

A firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, the nurse identifies tachycardia, tachypnea, and dyspnea. The nurse auscultates the client's lungs and expects to hear which type of breath sound? -Stridor -Rhonchi -Crackles -Wheezes

-Stridor

Which clinical manifestations would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? Select all that apply. One, some, or all responses may be correct. -Tachycardia -Restlessness -Warm, moist skin -Decreased urinary output -Bradypnea

-Tachycardia -Restlessness -Decreased urinary output

Which examples will the nurse use to describe occupational hazards for burn injuries when teach a safety class on burns? Select all that apply. One, some, or all responses may be correct. -Tar -Power lines -Fertilizers -Radiators -Outdoor grills

-Tar -Power lines -Fertilizers

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as an indicator that the client is experiencing complications of this therapy? -Tarry stools -Nausea and vomiting -Orange-colored urine -Decreased urine output

-Tarry stools Thrombolytic agents are used to dissolve existing thrombi, and the nurse should monitor the client for obvious or occult signs of bleeding.

The nurse is caring for a client with severe burns 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? -Milk -Tea -Orange juice -Tomato juice

-Tea

A patient has a chest tube inserted to treat a pneumothorax. Which observation causes the nurse to conclude that the water-seal chamber of the chest drainage unit (CDU) is functioning properly? -There is no bubbling in the suction control chamber. -The wall suction regulator is set to 150 mm Hg. -The level in the water-seal chamber fluctuates with respirations. -There is bloody drainage present in the water-seal chamber.

-The level in the water-seal chamber fluctuates with respirations.

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? -The client is not experiencing dyspnea. -The client is not experiencing nausea or vomiting. -The pain has not been relieved by rest and nitroglycerin tablets. -The client says the pain began while she was trying to open a stuck dresser drawer.

-The pain has not been relieved by rest and nitroglycerin tablets. The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief.

A patient with chronic obstructive pulmonary disease is being considered for lung transplantation. The patient's medical history includes melanoma and hepatitis A, and the patient is not a current smoker. Which statement is true regarding transplantation eligibility? -The patient is eligible for lung transplantation. -Because of the history of smoking, the patient is not eligible. -Because of the history of hepatitis A, the patient is not eligible. -Because of the history of cancer, the patient is not eligible.

-The patient is eligible for lung transplantation.

Of the four assigned patients on the intensive care unit (ICU), which patient would the critical care nurse identify as having the highest risk of developing delirium? -The patient sitting at the edge of the bed during physical therapy -The patient conversing with a family member about the weather -The patient whose ventilator is continuously alarming during suctioning -The patient who has dexmedetomidine (Precedex) ordered for insomnia

-The patient whose ventilator is continuously alarming during suctioning

A patient with metastatic lung cancer is suspected to have malnutrition. The nurse reviews the results of the serum albumin and serum prealbumin laboratory studies. How does the nurse interpret the findings? -If the albumin level is normal, then the patient does not have protein malnutrition. -The albumin level is an excellent indicator of acute changes in nutritional status. -Decreased levels of both indicate that malnutrition is present. -The prealbumin level more accurately reflects the patient's nutritional status.

-The prealbumin level more accurately reflects the patient's nutritional status.

A client sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention but the client refuses. The nurse would instruct the client to go see a primary health care provider if which change occurs? -Blisters appear -Urinary output decreases -Edema and redness occur -White patches develop

-Urinary output decreases

Which action will the nurse take when caring for a patient with acute respiratory failure due to left-sided pneumonia? -Suction the patient every hour. -Avoid hyperventilating the patient. -Position the patient with the good lung up. -Use huff coughing to help to clear secretions.

-Use huff coughing to help to clear secretions.

Which action would the nurse take when caring for a client with burns who is being treated with collagenase and polysporin powder therapy? -Apply the treatment twice a day. -Monitor arterial blood gas levels. -Use the treatment on partial-thickness wounds with eschar. -Avoid a barrier dressing such as occlusive petrolatum gauze

-Use the treatment on partial-thickness wounds with eschar.

A client admitted with severe burns, obesity, and with preexisting respiratory problems is at risk for which complication? -Necrosis -Pneumonia -Dysrhythmias -Venous thromboembolism

-Venous thromboembolism

A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? -Pulsus paradoxus -Ventricular dysrhythmias -Rising diastolic blood pressure -Falling central venous pressure

-Ventricular dysrhythmias Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Pulsus paradoxus is a finding associated with cardiac tamponade.

Which elements are included in the assessment of the tissue perfusion of a patient experiencing shock? Select all that apply. -Vital signs -Urine output -Lung sounds -Peripheral pulses -Skin temperature -Level of consciousness

-Vital signs -Urine output -Peripheral pulses -Skin temperature -Level of consciousness

Which condition does a patient with cardiogenic shock typically experience? -Hypotension -Dysrhythmias -Volume excess -Volume depletion

-Volume excess

A client who sustained serious burns now has a stress ulcer. If complications occur, which clinical indicators of shock would the nurse immediately report to the primary health care provider? Select all that apply. One, some, or all responses may be correct. -Weakness -Diaphoresis -Tachycardia -Cold extremities -Flushed skin tone

-Weakness -Diaphoresis -Tachycardia -Cold extremities

The nurse is planning care to prevent deformities and contractures in a client with burns. When would the nurse begin range-of-motion (ROM) exercises? -When pain has lessened -When vital signs are stable -When skin grafts are healed -When emotional status stabilizes

-When vital signs are stable

The nurse provides care for a patient who has third-degree burns and a paralytic ileus. Which type of intervention is appropriate for long-term support of nutrition for the patient? Oral nutrition Enteral nutrition Central parenteral nutrition Peripheral parenteral nutrition

Central parenteral nutrition

Which cardiac parameters would the nurse assess to determine the adequacy of fluid resuscitation in a patient who has sustained burns? Select all that apply. -Heart rate less than 120 beats/minute -Manual systolic BP greater than 90 mm Hg -Arterial line systolic BP greater than 90 mm Hg -Manual mean arterial pressure greater than 65 mm Hg -Arterial line mean arterial pressure greater than 65 mm Hg

Heart rate less than 120 beats/minute Arterial line systolic BP greater than 90 mm Hg Arterial line mean arterial pressure greater than 65 mm Hg