Shock, Burns, SCI, and Emergency Nursing NCLEX Study Questions
A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank 20 minutes. Which of the following is the most important instruction the nurse can give the parent? A: This too shall pass. B: Take the child immediately to the ER C: Contact the Poison Control Center quickly D: Give the child syrup of ipecac
(C) The poison control center will have an exact plan of action for this child.
You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting 1. A B D C 2. B A D C 3. C D B A 4. C B A D
2. An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary.
A patient is undergoing a escharotomy. Which of the following is correct about the procedure? A. It is performed on circumferential burns and is usually performed at bedside without anesthesia. B. It is performed on radiation burns and requires general anesthesia. C. It is performed if tissue perfusion does NOT return after a fasciotomy. D. None of the options are correct.
A Escharotomy are performed at the beside without anesthia because the nerves are already damaged. It is first performed when a patient has a circumferential burn and if tissue perfusion fails to return a fasciotomy is performed in the operating room.
The emergency service team brings a client to the emergency department. The client was found lying in an alley near a Dumpster by a policeman, who reports that the client is a homeless victim. An assessment is performed, and the client is suspected of having frostbite of the hands. Which of the following findings would the nurse note in this condition? a) a white appearance to the skin that is insensitive to touch b) a pink edematous hand c) black fingertips surrounded by an erythematous rash d) resd skin with edema in the nail beds
A - Assessment findings in frostbite include a white or blue appearance, and the skin will be hard, cold, and insensitive to touch. As thawing occurs, the skin becomes flushed, blisters or blebs develop, or tissue edema appears. Gangrene develops in 9 to 15 days
You are helping the patient with an SCI to establish a bladder-retraining program. What strategies may stimulate the patient to void? (Choose all that apply). A. Stroke the patient's inner thigh. B. Pull on the patient's pubic hair. C. Initiate intermittent straight catheterization. D. Pour warm water over the perineum. E. Tap the bladder to stimulate detrusor muscle
A, B, D, E All of the strategies, except straight catheterization, may stimulate voiding in patients with SCI. Intermittent bladder catheterization can be used to empty the patient's bladder, but it will not stimulate voiding.
The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. A. Elevate the HOB to 90 degrees B. Loosen constrictive clothing C. Use a fan to reduce diaphoresis D. Assess for bladder distention and bowel impaction E. Administer antihypertensive medication
A, B, D, E The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia.
The patient with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient the nurse may delegate which action (s) to the LPN/LVN? (Choose all that apply). A. Check the patient's skin for pressure form device. B. Assess the patient's neurologic status for changes. C. Observe the halo insertion sites for signs of infection. D. Clean the halo insertion sites with hydrogen peroxide
A, C, D Checking and observing for signs of pressure or infection are within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic examination requires additional education and skill appropriate to the professional RN
After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? A. Quadriplegia with gross arm movement and diaphragmatic breathing B. Quadriplegia and loss of respiratory function C. Paraplegia with intercostal muscle loss D. Loss of bowel and bladder control
A. A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.
In a multiple-trauma victim, which assessment finding signals the most serious and life-threatening condition? A. A deviated trachea B. Gross deformity in a lower extremity C. Decreased bowel sounds D. Hematuria
A. A deviated trachea is a symptoms of tension pneumothorax. All of the other symptoms need to be addressed, but are of lesser priority.
A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? A. Begin intravenous fluids B. Check the pulses with a Doppler device C. Obtain a complete blood count (CBC) D. Obtain an electrocardiogram (ECG)
A. Begin IV fluids Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injuries. Fluids can treat this problem. An ECG and CBC will be taken to ascertain if a cardiac or bleeding problem is causing these vital signs. However these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery but this is not an immediate nursing action.
Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery? A. Changing gloves between wound care on different parts of the client's body. B. Avoiding sharing equipment such as blood pressure cuffs between clients. C. Using the closed method of burn wound management. D. Using proper and consistent handwashing.
A. Changing gloves between wound care on different parts of the body Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on difference parts of the client's body can prevent autocontamination.
On admission to the emergency department the burned client's blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury-related response? A. Fluid shift B. Intense pain C. Hemorrhage D. Carbon monoxide poisoning
A. Fluid shift Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage is unusual in a burn injury. The physiologic effect of histamine release in injured tissues is a loss of vascular volume to the interstitial space, with a resulting decrease in blood pressure.
Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds? A. Handwashing on entering the client's room B. Encouraging the client to cough and deep breathe C. Administering the prescribed tetanus toxoid vaccine D. Changing gloves between cleansing different burn areas
A. Handwashing upon entering room Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Although all the interventions listed above can help reduce the risk for infection, only hand washing can prevent cross contamination.
Which type of shock is associated with low blood levels? A. Hypovolemic shock B. Septic shock C. Anaphylactic shock D. Cardiogenic shock
A. Hypovolemic Shock
A patient with 55% burns is groaing out in pain and rates pain 10 on 1-10 scale. You have PRN orders for the following medications. What is the best option for this patient? A. IV Morphine B. Oral Lortab liquid suspension C. IM Demerol D. Subcutaneous Demerol
A. IV morphine IV route is the best option when a patient has burns. If a medication is given IM or subq, hypovolemia may disrupt absorption. In addition, oral route should be avoid due to potential GI dysfunction.
Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery? A. Increased urine output, decreased urine specific gravity B. Increased peripheral edema, decreased blood pressure C. Decreased peripheral pulses, slow capillary refill D. Decreased serum sodium level, increased hematocrit
A. Increased urine and decreased urine specific gravity The "fluid remobilization" phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity.
A tearful parent brings a child to the ED for taking an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician? A. The ingested children's chewable vitamins contain iron. B. The child has been treated several times for ingestion of toxic substances. C. The child has been treated several times for accidental injuries. D. The child was nauseated and vomited once at home
A. Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. Other information needs additional investigation, but will not change the immediate diagnostic testing or treatment plan.
A patient is being discharge after having autografting. What would you include in your discharge education? A. Keep the site free from pressure and keep the site lubricated. B. Encourage for the site to be exposed to sunlight to promoted melanin production. C. Avoid using splints or any type of support garment. D. Encourage weight-bearing exercise every 4 to 6 hours.
A. Keep site from pressure and keep lubricated The patient should avoid the sunlight due to increase risk of sunburn to delicate skin. In addition, the patient should avoid weight-bearing activites to prevent damage to the newly grafted skin. It is best to encourage splints and support garments to protect the skin during acitiviy.
The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant? A. Chest compressions B. Bag-valve mask ventilation C. Assisting with oral intubation D. Placing the defibrillator pads
A. Nursing assistants are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide PRN assistance during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.
You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is your priority intervention for this patient? A. Transportation arrangements to a safe house B. Referral to a counselor C. Advice about contacting the police D. Follow-up appointment for injuries
A. Safety is a priority for this patient, and she should not return to a place where violence could occur. The other options are important for the long term management of this care.
The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant? A. Assist the child to remove outer clothing. B. Advise the parent to use acetaminophen instead of aspirin. C. Explain the need for cool fluids. D. Prepare and administer a tepid bath.
A. The nursing assistant can assist with the removal of the outer clothing, which allows the heat to dissipate from the child's skin. Advising and explaining are teaching functions that are the responsibility of the RN. Tepid baths are not usually performed because of potential for rebound and shivering.
Your patient is in the progressive stage of shock. If the shock is not corrected and tissue hypoxia occurs, what would happen with the patients metabolism? A. The tissues will undergo anaerobic metabolism, creating lactic acid and lowering the tissue pH B. Vasomotor reflex of arteriolar constriction that reduces pooling of blood in the microcirculation C. Metabolism would be unaffected by the lower oxygen level for the 2-3 hours
A. The tissues will undergo anaerobic metabolism, creating lactic acid and lowering the tissue pH
The nurse is preparing to administer Lactate Ringer's to a client with hypovolemic shock. Which intervention is important in helping to stabilize the client's condition? A. Warming the intravenous fluids B. Determining whether the client can take oral fluids C. Checking for the strength of pedal pulses D. Obtaining the specific gravity of the urine
A. Warming the intravenous fluids
Which patient is at risk for compartment syndrome due to a burn? A. A 25 year old with circumferential burn of the anterior and posterior left arm. B. A 7 year old with a burn of the left and right ear. C. A 55 year old with an electrical burn on the neck. D. A 15 year old with a chemical burn to the right foot
A. anterior and posterior arm Circumferential burns of the extremities produce a tourniquet like effect and leads to vascular problems.
As a nurse working on a burn unit, which of your patients are at high risk for internal tissue damage? A. Patient in room 2101 with an electrical burn on torso. B. Patient in room 2106 with a radiation burn on the abdomen. C. Patient in room 2103 with a thermal burn to peritoneal area. D. Patient in room 2101 with a chemical burn to face.
A. electrical burn Electrical burns are caused by heat generated by electrical current which is transferred through the body. This current burns the skin but also affects internal tissue as well.
A preceptor is observing a nursing student provide care to a patient with major burns to the face and head. What nursing intervention does the student perform correctly? A. Elevates the head of the bead at 30'. B. Uses gloves and face mask when providing care. C. Places the patient in trendelenburg position. D. Assist the patient with eating food tray
A. elevate HOB Due to edema and respiratory issues patient with facial burns should have the HOB at 30'. In additon, strict isolation protocol is implemented because they patient is at high risk for infection ( gloves and facial mask are not sufficent enough)
A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding
A. teaching on self-cath measures
The nurse is triaging four clients injured in a train derailment. Which client should receive priority treatment? A 42-year-old with dyspnea and chest asymmetry b 17-year-old with a fractured arm C 4-year-old with facial lacerations D.A 30-year-old with blunt abdominal trauma
Answer A is correct. Following the ABCDs of basic emergency care, the client withdyspnea and asymmetrical chest should be cared for first because thesesymptoms are associated with flail chest. Answer D is incorrect because he shouldbe cared for second because of the likelihood of organ damage and bleeding.Answer B is incorrect because he should be cared for after the client withabdominal trauma. Answer C is incorrect because he should receive care lastbecause his injuries are less severe
An unresponsive client is admitted to the emergency room with a history of diabetes mellitus. The client's skin is cold and clammy, and the blood pressure reading is 82/56. The first step in emergency treatment of the client's symptoms would be: A.Checking the client's blood sugar B. Administering intravenous dextrose C. Intubation and ventilator support D. Administering regular insulin
Answer A is correct. The client has symptoms of insulin shock and the first step is to check the client's blood sugar. If indicated, the client should be treated with intravenous dextrose. Answer B is wrong because it is not the first step the nurse should take. Answer C is wrong because it does not apply to the client's symptoms. Answer D is wrong because it would be used for diabetic ketoacidosis,not insulin shock.
A client with a history of severe depression has been brought to the emergency room with an overdose of barbiturates. The nurse should pay careful attention to the client's: A. Urinary output B. Respirations C. Temperature D. Verbal responsiveness
Answer B is correct. Barbiturate overdose results in central nervous system depression, which leads to respiratory failure. Answers A and C are important to the client's overall condition but are not specific to the question, so they are incorrect. The use of barbiturates results in slow, slurred speech, so answer D is expected, and therefore incorrect.
Direct pressure to a deep laceration on the client's lower leg has failed to stop the bleeding. The nurse's next action should be to: A. Place a tourniquet proximal to the laceration. B. Elevate the leg above the level of the heart. C. Cover the laceration and apply an ice compress D. Apply pressure to the femoral artery
Answer B is correct. If bleeding does not subside with direct pressure, the nurseshould elevate the extremity above the level of the heart. Answers A and D aredone only if other measures are ineffective, so they are incorrect. Answer C wouldslow the bleeding but will not stop it, so it's incorrect
A client is to receive antivenin following a snake bite. Before administering the antivenin, the nurse should give priority to: A. Administering a local anesthetic B. Checking for an allergic response C. Administering an anxiolytic D.Withholding fluids for 6 - 8 hours
Answer B is correct. The nurse should perform the skin or eye test before administering antivenin. Answers A and D are unnecessary and therefore incorrect. Answer C would help calm the client but is not a priority before giving the antivenin, making it incorrect.
You are working in the triage area of an ED, and four patients approach the triage desk at the sametime. List the order in which you will assess these patients. a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting
Answer: B, A, D, C - An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24-48 hours if necessary
Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority? A. A patient with low-grade fever, headache, and myalgias for the past 72 hours. B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident. C. A patient with abdominal and chest pain following a large, spicy meal. D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.
Answer: C Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be sutured but is also non-urgent.
A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority? A. A complete history with emphasis on preceding events. B. An electrocardiogram. C. Careful assessment of vital signs. D. Chest exam with auscultation.
Answer: C The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.
A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category? a. High urgent b. Urgent c. Non-urgent d. Emergent
Answer: D - Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones).Non-urgent conditions can wait for hours or even days. (High urgent is not commonly used; however, in5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the timelapsing prior to treatment).
An emergency department nurse prepares to treat a client who has frostbite of the toes from prolonged exposure during an ice-fishing trip. Which of the following would the nurse anticipate to be prescribed for this condition? a) rapid rewarming of the toes in hot water b) rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs c) rapid and continuous alternating cold and hot soaks of the toes d) rapid rewarming of the toes by soaking in cold water for 45 minutes
B - Acute frostbite is ideally treated with rapid and continuous rewarming of the tissue in a water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because this can contribute to increased cellular damage. Thawing can cause considerable pain, and the nurse would administer analgesics as prescribed.
A mother arrives at the emergency department with her child, stating that she just found the child sitting on the floor next to an empty bottle of aspirin. On assessment, the nurse notes that the child is drowsy but conscious. The nurse anticipates that the physician will prescribe which of the following? a) ipecac syrup b) activated charcoal c) magnesium citrate d) magnesium sulfate
B - Whereas ipecac is administered to induce vomiting in certain poisoning situations, it is not recommended as the initial treatment in the hospital setting for ingestion of salicylates. This is because ipecac does not totally remove the poison from the child's system. In this situation, the child is conscious and the ingested substance (aspirin) would not damage the esophagus or lungs from vomiting. However, activated charcoal would be prescribed as an antidote in this poisoning situation, because its action is to absorb ingested toxic substances and thus decrease absorption. Options C and D are unrelated to treatment for this occurrence.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. a. Perform the chin lift or jaw thrust maneuver. b. Establish unresponsiveness. c. Initiate cardiopulmonary resuscitation (CPR). d. Call for help and activate the code team. e. Instruct a nursing assistant to get the crash cart.
B D A C E Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.
A patient who is in cardiogenic shock has a urine output of 20mL/hr. When further assessing the patient's renal function, what additional findings are anticipated? Select all that apply. A. Decreased urine specific gravity B. Increased blood urea nitrogen (BUN) C. Decreased urine sodium D. Decreased serum creatinine
B Increased BUN C. Decreased urine sodium
A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1 being the first priority and number 5 being the last priority). A. Check for bladder distention B. Raise the head of the bed C. Contact the physician D. Loosen tight clothing on the client E. Administer an antihypertensive medication
B, D, A, C, E Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a foley catheter, the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.
A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? A. "There was a lot of blood and we used three bandages." B. "He pulled the stick out, just now, because it was hurting him." C. "The stick was really dirty and covered with mud." D. "He's a diabetic, so he needs attention right away
B. An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss, depth of penetration, and medical history should be obtained. Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment plan, but can be addressed later.
What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures? A. "For the first few days after surgery, the donor sites will be painful." B. "Because the graft is my own skin, there is no chance it won't 'take'." C. "I will have some scarring in the area when the skin is removed for grafting." D. "Once all grafting is completed, my risk for infection is the same as it was before I was burned."
B. Because it is my own skin Factors other than tissue type, such as circulation and infection, influence whether and how well a graft "takes." The client should be prepared for the possibility that not all grafting procedures will be successful.
A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.
B. Check BP Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP
Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? A. Colloids B. Crystalloids C. Fresh-frozen plasma D. Packed red blood cells
B. Crystalloids Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringer's lactate. The burn client rarely requires blood during the emergent phase unless the burn is complicated by another injury that involved hemorrhage. Colloids and plasma are not generally used during the fluid shift phase because these large particles pass through the leaky capillaries into the interstitial fluid, where they increase the osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen the capillary leak syndrome and make maintaining the circulating fluid volume even more difficult.
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse's best action? A. Reposition the client onto the right side. B. Document the finding as the only action. C. Notify the emergency team. D. Increase the IV flow rate
B. Document Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response, and it is not the highest priority of care at this time.
Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse's best action? A. Notify the emergency team. B. Document the finding as the only action. C. Ask the client if anyone in her family has diabetes mellitus. D. Slow the intravenous infusion of dextrose 5% in Ringer's lactate
B. Document Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first? A. Administer the ordered acetaminophen (Tylenol). B. Check the Foley tubing for kinks or obstruction. C. Adjust the temperature in the patient's room. D. Notify the physician about the change in status
B. Foley These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem. Tylenol will not decrease the autonomic dysreflexia that is causing the patient's headache. Notification of the physician may be necessary if nursing actions do not resolve symptoms. Focus: Prioritization
A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.
B. Full function of the patients arms will be retained
A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? A. Decreased urine output or oliguria B. Hypertension and bradycardia C. Respiratory depression D. Symptoms of shock
B. HTN and bradycardia Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect.
The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission? A. Airway patency B. Heart rate and rhythm C. Orientation to time, place, and person D. Current range of motion in all extremities
B. Heart rate and rhythm The airway is not at any particular risk with this injury. Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes.
The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: A. A flattened abdomen B. Hematest positive nasogastric tube drainage C. Hyperactive bowel sounds D. A history of diarrhea
B. Hematest positive NG drainage After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool. A history of diarrhea is irrelevant.
A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98, heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40. The healthcare provider suspects which type of shock? A. Cardiogenic B. Hypovolemic C. Neurogenic D. Distributive
B. Hypovolemic
A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus? A. PO phenytoin and carbamazepine B. IV lorazepam (Ativan) C. IV carbamazepine D. IV magnesium sulfate
B. IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. PO (per os) medications are inappropriate for this emergency situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy.
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? A. To hasten wound healing B. To immobilize the cervical spine C. To prevent autonomic dysreflexia D. To hold bony fragments of the skull together
B. Immobilize cervical spine Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished
What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury? A. Acute Pain B. Impaired Adjustment C. Deficient Diversional Activity D. Imbalanced Nutrition: Less than Body Requirements
B. Impaired adjustment Recovery from a burn injury requires a lot of work on the part of the client and significant others. Seldom is the client restored to the preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client. By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem.
Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage B. Schedule intermittent catheterization every 2 to 4 hours C. Perform a straight catheterization every 8 hours while awake D. Perform Crede's maneuver to the lower abdomen before the client voids
B. Intermittent cath Q2-4H Intermittent catherization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible. Crede's maneuver is not used on people with spinal cord injury.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program B. Limiting bladder catheterization to once every 12 hours C. Keeping the linen wrinkle-free under the client D. Preventing unnecessary pressure on the lower limbs
B. Limiting bladder cath to once Q12H The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catherization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action? A. Administer oxygen. B. Loosen the dressing. C. Notify the emergency team. D. Document the observation as the only action
B. Loosen dressing Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client's respiratory status.
The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action? A. Raise the head of the bed. B. Notify the emergency team. C. Loosen the dressings on the chest. D. Document the findings as the only action
B. Notify the emergency team Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway and the swelling usually precludes intubation.
The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
B. Partial-thickness superficial The characteristics of the wound meet the criteria for a superficial partial thickness injury (color that is pink or red; blisters; pain present and high).
All of the following laboratory test results on a burned client's blood are present during the emergent phase. Which result should the nurse report to the physician immediately? A. Serum sodium elevated to 131 mmol/L (mEq/L) B. Serum potassium 7.5 mmol/L (mEq/L) C. Arterial pH is 7.32 D. Hematocrit is 52%
B. Potassium 7.5 All these findings are abnormal; however, only the serum potassium level is changed to the degree that serious, life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death.
What is the treatment of choice to correct Hypovolemic Shock? A. Have the patient drink a large bottle of Gatorade. B. Replace fluids intravenously as quickly as possible. C. Administer a vasopressor D. All of the above.
B. Replace fluids intravenously as quickly as possible
You are assigned to telephone triage. A patient who was stung by a common honey bee calls for advice, reports pain and localized swelling, but denies any respiratory distress or other systemic signs of anaphylaxis. What is the action that you should direct the caller to perform? A. Call 911. B. Remove the stinger by scraping. C. Apply a cool compress. D. Take an oral antihistamine
B. The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911 assistance.
You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when providing nursing care for a patient with SCI? A. Assess patient's respiratory status every 4 hours. B. Take patient's vital signs and record every 4 hours. C. Monitor nutritional status including calorie counts. D. Have patient turn, cough, and deep breathe every 3 hours
B. Vital signs The nursing assistant's training and education include taking and recording patient's vital signs. The nursing assistant may assist with turning and repositioning the patient and may remind the patient to cough and deep breathe but does not teach the patient how to perform these actions. Assessing and monitoring patients require additional education and are appropriate to the scope of practice for professional nurses. Focus: Delegation/supervision
The burned client's family ask at what point the client will no longer be at increased risk for infection. What is the nurse's best response? A. "When fluid remobilization has started." B. "When the burn wounds are closed." C. "When IV fluids are discontinued." D. "When body weight is normal."
B. When burn wounds are closed Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open.
You are caring for a victim of frostbite to the feet. Place the following interventions in the correct order. a. Apply a loose, sterile, bulky dressing. b. Give pain medication. c. Remove the victim from the cold environment. d. Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C)
C B D A The victim should be removed from the cold environment first, and then the rewarming process can be initiated. It will be painful, so give pain medication prior to immersing the feet in warmed water.
A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient. a. Secure/start two large-bore IVs with normal saline b. Use the chin lift or jaw thrust method to open the airway. c. Assess for spontaneous respirations d. Give supplemental oxygen per mask. e. Obtain a full set of vital signs. f. Remove patient's clothing. g. Insert a Foley catheter if not contraindicated.
C B D A E F G For a multiple trauma victim, many interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However, airway and oxygenation are priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to closely monitor output.
Following emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function? a. Obtain an order for a chest x-ray to document tube placement. b. Secure the tube in place. c. Auscultate the chest during assisted ventilation. d. Confirm that the breath sounds are equal and bilateral.
C D B A Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study.
When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? A. An interval when the client's speech is garbled. B. An interval when the client is alert but can't recall recent events. C. An interval when the client is oriented but then becomes somnolent. D. An interval when the client has a "warning" symptom, such as an odor or visual disturbance.
C. A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Complete set of vital signs B. Palpation and auscultation of the abdomen C. Brief neurologic assessment D. Initiation of pulse oximetry
C. A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey. Question 4 CORRECT
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs
C. Assessment of respiratory rate and depth
The burned client on admission is drooling and having difficulty swallowing. What is the nurse's best first action? A. Assess level of consciousness and pupillary reactions. B. Ask the client at what time food or liquid was last consumed C. Auscultate breath sounds over the trachea and mainstem bronchi D. Measure abdominal girth and auscultate bowel sounds in all four quadrants
C. Auscultate breath sounds Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client's airway is in severe jeopardy and intubation is highly likely to be needed shortly.
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A. Positive reflexes B. Hyperreflexia C. Inability to elicit a Babinski's reflex D. Reflex emptying of the bladder
C. Babinski's reflex Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.
What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn? A. The burn is full thickness rather than partial thickness. B. The client is unable to fully pronate and supinate the extremity. C. Capillary refill is slow in the digits and the distal pulse is absent. D. The client cannot distinguish the sensation of sharp versus dull in the extremity.
C. Capillary refill is slow in the digits and the distal pulse is absent Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure and preventing blood flow to the distal extremities and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb. This problem can be reduced or corrected with an escharotomy.
What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire? A. Pulse oximetry reading of 80% B. Expiratory stridor and nasal flaring C. Cherry red color to the mucous membranes D. Presence of carbonaceous particles in the sputum
C. Cherry red color to mucous membranes The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a "cherry red" color of the mucous membranes in these clients. The other manifestations are associated with inhalation injury, but not specifically carbon monoxide poisoning.
The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurse's best response? A. "To increase the urine output and prevent kidney damage." B. "To stimulate intestinal movement and prevent abdominal bloating." C. "To decrease hydrochloric acid production in the stomach and prevent ulcers." D. "To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock."
C. Decrease hydrochloric acid production Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.
What causes decreased BP in neurogenic shock? A. Movement of fluid into the cells B. Movement of fluid into the vasculature C. Disrupted SNS communication D. Polyuria
C. Disrupted SNS communication
A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? A. How to maintain home smoke detectors B. Joining a community reintegration program C. Learning to perform dressing changes D. Options available for scar removal
C. Dressing changes Critical for the goal of progression toward independence for the client is teaching clients and family members to perform care tasks such as dressing changes. All the other distractors are important in the rehabilitation stage. However, dressing changes have priority.
At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? A. Immediately following the injury B. During the fluid shift C. During fluid remobilization D. During the late acute phase
C. During fluid remobilization Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output.
A child is brought to the emergency room by his mother who reports the child was stung by a bee while playing in the back yard. The child has an itchy rash on the face, neck, and chest. Breathing is labored with audible wheezing. Which of these medications should the healthcare provider administer first? A. Diphenhydramine B. Albuterol C. Epinephrine D. Dopamine
C. Epinephrine
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A. A client with a brain injury B. A client with a herniated nucleus pulposus C. A client with a high cervical spine injury D. A client with a stroke
C. High cervical spine injury Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia.
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? A. Antibiotics to treat the underlying infection. B. Corticosteroids to reduce inflammation. C. IV fluids to increase intravascular volume. D. Vasopressors to increase blood pressure.
C. IV fluids to increase intravascular volume
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? A. Assess full ROM to determine extent of injuries B. Call for an immediate chest x-ray C. Immobilize the client's head and neck D. Open the airway with the head-tilt chin-lift maneuver
C. Immobilize head and neck All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. ROM would be contraindicated at this time. There is no indication that the client needs a chest x-ray. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver wouldn't be used until the cervical spine injury is ruled out.
You are preparing a nursing care plan for the patient with SCI including the nursing diagnosis Impaired Physical Mobility and Self-Care Deficit. The patient tells you, "I don't know why we're doing all this. My life's over." What additional nursing diagnosis takes priority based on this statement? A. Risk for Injury related to altered mobility B. Imbalanced Nutrition, Less Than Body Requirements C. Impaired Adjustment to Spinal Cord Injury D. Poor Body Image related to immobilization
C. Impaired Adjustment The patient's statement indicates impairment of adjustment to the limitations of the injury and indicates the need for additional counseling, teaching, and support. The other three nursing diagnoses may be appropriate to the patient with SCI, but they are not related to the patient's statement
The client with a full-thickness burn is being discharged to home after a month in the hospital. His wounds are minimally opened and he will be receiving home care. Which nursing diagnosis has the highest priority? A. Acute Pain B. Deficient Diversional Activity C. Impaired Adjustment D. Imbalanced Nutrition: Less than Body Requirements
C. Impaired adjustment Recovery from a burn injury requires a lot of work on the part of the client and significant others. The client is seldom restored to his or her preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client. By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem.
A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? A. By inserting a nasopharyngeal airway B. By inserting a oropharyngeal airway C. By performing a jaw-thrust maneuver D. By performing the head-tilt, chin-lift maneuver
C. Jaw-thrust maneuver If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury.
Louie, with burns over 35% of the body, complains of chilling. In promoting the client's comfort, the nurse should: A. Maintain room humidity below 40% B. Place top sheet on the client C. Limit the occurrence of drafts D. Keep room temperature at 80 degrees
C. Limit drafts A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.
The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? A. Seasonal asthma B. Hepatitis B 10 years ago C. Myocardial infarction 1 year ago D. Kidney stones within the last 6 month
C. MI 1 year ago It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation
The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess a. blood pressure and heart rate. b. respiratory effort and O2 saturation. c. motor and sensory function of the legs. d. bowel sounds and abdominal distension
C. Motor and sensory function of the legs
The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? A. Monitoring vital signs before and during position changes B. Using vasopressor medications as prescribed C. Moving the client quickly as one unit D. Applying Teds or compression stockings
C. Moving the client quickly as one unit Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Measures to minimize this include measuring vital signs before and during position changes, use of a tilt-table with early mobilization, and changing the client's position slowly. Venous pooling can be reduced by using Teds (compression stockings) or pneumatic boots. Vasopressor medications are administered per protocol.
A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis
C. Neurogenic Shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Hypervolemia is indicated by rapid and bounding pulse and edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.
While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A. Autonomic dysreflexia B. Hemorrhagic shock C. Neurogenic shock D. Pulmonary embolism
C. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.
A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock? A. Distributive B. Neurogenic C. Obstructive D. Cardiogenic
C. Obstructive
You are preparing a child for IV conscious sedation prior to repair of a facial laceration. What information should you immediately report to the physician? A. The parent is unsure about the child's tetanus immunization status. B. The child is upset and pulls out the IV. C. The parent declines the IV conscious sedation. D. The parent wants information about the IV conscious sedation.
C. Parent refusal is an absolute contraindication; therefore, the physician must be notified. Tetanus status can be addressed later. The RN can restart the IV and provide information about conscious sedation; if the parent still not satisfied, the physician can give more information.
Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the: A. Total volume of circulating whole blood B. Total volume of intravascular plasma C. Permeability of capillary walls D. Permeability of kidney tubules
C. Permeability of capillary walls In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
When an unexpected death occurs in the ED, which of the following tasks is most appropriate to delegate to the nursing assistant? A. Escort the family to a place of privacy. B. Go with the organ donor specialist to talk to the family. C. Assist with postmortem care. D. Assist the family to collect belongings
C. Postmortem care requires some turning, cleaning, lifting, etc., and the nursing assistant is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained.
Which stage of shock is associated with the worsening of tissue hypoperfusion and onset of worsening circulatory and metabolic imbalances, including acidosis? A. Initial nonprogressive phase B. Developing phase C. Progressive stage D. Irreversible stage
C. Progressive Stage
Which of the following strategies is NOT effective for prevention of Lyme disease? A. Insect repellant on the skin and clothes when in a Lyme endemic area. B. Long sleeved shirts and long pants. C. Prophylactic antibiotic therapy prior to anticipated exposure to ticks. D. Careful examination of skin and hair for ticks following anticipated exposure.
C. Prophylactic antibiotic
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A. Bladder distension B. Neurological deficit C. Pulse ox readings D. The client's feelings about the injury
C. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority.
A nurse is performing an assessment on a client who has a suspected spinal cord injury. Which of the following is the priority nursing assessment? a) pain level b) mobility level c) respiratory status d) pupillary response
C. Respiratory status All of these assessments would be performed on a client with a suspected spinal cord injury. However, respiratory status is the priority.
What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm? A. Risk for Ineffective Breathing Pattern B. Decreased Tissue Perfusion C. Risk for Disuse Syndrome D. Disturbed Body Image
C. Risk for disuse syndrome During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury
A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? A. Acetazolamide (Diamox) B. Furosemide (Lasix) C. Methylprednisolone (Solu-Medrol) D. Sodium bicarbonate
C. Solu-Medrol High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance
In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN? A. Assess immediate emotional state and physical injuries B. Collect hair samples, saliva swabs, and scrapings beneath fingernails. C. Provide emotional support and supportive communication. D. Ensure that the "chain of custody" is maintained
C. The LPN/LVN is able to listen and provide emotional support for her patients. The other tasks are the responsibility of an RN or, if available, a SANE (sexual assault nurse examiner) who has received training to assess, collect and safeguard evidence, and care for these victims.
Which client factors should alert the nurse to potential increased complications with a burn injury? A. The client is a 26-year-old male. B. The client has had a burn injury in the past. C. The burned areas include the hands and perineum. D. The burn took place in an open field and ignited the client's clothing.
C. The burned areas include the hands and perineum Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome.
The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? A. The medication will be effective more quickly than if given intramuscularly. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client delayed gastric emptying
C. The danger of an overdose during fluid remobilization is reduced Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.
An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for the nurse? A. Trauma team B. Triage C. Ambulatory or fast track clinic D. Pediatric medicine team
C. The fast track clinic will deal with relatively stable patients. Triage, trauma, and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment.
A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN? A. Gently cleanse the amputated digits with Betadine solution. B. Place the amputated digits directly into ice slurry. C. Wrap the amputated digits in sterile gauze moistened with saline. D. Store the amputated digits in a solution of sterile normal saline
C. The only correct intervention is C. the digits should be gently cleansed with normal saline, wrapped in sterile gauze moistened with saline, and placed in a plastic bag or container. The container is then placed on ice.
An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? A. Notify the physician immediately. B. Administer supplemental oxygen. C. Have the student breathe into a paper bag. D. Obtain an order for an anxiolytic medication
C. The patient is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen and medication may be needed if other causes are identified.
You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? A. An advanced practice nurse and an experienced LPN/LVN B. An experienced LPN/LVN and an inexperienced RN C. An experienced RN and an inexperienced RN D. An experienced RN and a nursing assistant
C. Triage requires at least one experienced RN. Pairing an experienced RN with inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial patient assessment or decision making. Pairing an experienced RN with a nursing assistant is the second best option, because the assistant can obtain vital signs and assist in transporting.
The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury? A. Place a towel roll under the client's neck or shoulder. B. Keep the client in a supine position without the use of pillows. C. Have the client turn the head from side to side 90 degrees every hour while awake. D. Keep the client in a semi-Fowler's position and actively raise the arms above the head every hour while awake.
C. Turn head side to side The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion.
A patient who is in hypovolemic shock has the following clinical signs: Heart rate 120 beats/minute, blood pressure 80/55 and urine output 20ml/hr. After administering an IV fluid bolus, which of these signs if noted by the healthcare provider is the best indication of improved perfusion? A. Right atrial pressure increases B. Systolic blood pressure increases to 85 C. Urine output increases to 30ml/hr D. Heart rate drops to 100 beats/minute
C. Urine output increases to 30ml/hr
The client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide? A. "With reconstructive surgery, you can look the same." B. "We can remove the scars with the use of a pressure dressing." C. "You will not look exactly the same." D. "You shouldn't start worrying about your appearance right now."
C. You will not look exactly the same Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. Pressure dressings prevent further scarring. They cannot remove scars. The client and family should be taught the expected cosmetic outcomes.
Which information obtained by assessment ensures that the client's respiratory efforts are currently adequate? A. The client is able to talk. B The client is alert and oriented. C. The client's oxygen saturation is 97%. D. The client's chest movements are uninhibited
C. oxygen saturation is 97% Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.
A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients? a) a client complaining of muscle aches, a headache, and malaise b) a client who twisted her ankle when she fell while rollerblading c) a client with a minor laceration on the index finger sustained while cutting an eggplant d) a client with chest pain who states that he just ate pizza that was made with a very spicy sauce
D - In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority.
These patients present to the ED complaining of acute abdominal pain. Prioritize them in order of severity. a. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating b. A 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days c. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week d. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour
D B C A The patient with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate suddenly. The 11-year-old boy needs evaluation to rule out appendicitis. The woman needs evaluation for gallbladder problems that appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting
When should ambulation be initiated in the client who has sustained a major burn? A. When all full-thickness areas have been closed with skin grafts B. When the client's temperature has remained normal for 24 hours C. As soon as possible after wound debridement is complete D. As soon as possible after resolution of the fluid shift
D. As soon as possible after fluid shift Regular, progressive ambulation is initiated for all burn clients who do not have contraindications concomitant injuries as soon as the fluid shift resolves. Clients can be ambulated with extensive dressings, open wounds, and nearly any type of attached lines, tubing, and other equipment.
The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees is best suited to fulfill this assignment? A. ED physicians and charge nurses B. Experienced RNs and experienced paramedics C. RNs, LPN/LVNs, and nursing assistants D. At least one representative from each group of ED personnel
D. At least one representative from each group should be included because all employees are potential targets fro violence in the ED.
After falling from a 10' ladder, a patient is brought to the emergency department. The patient is alert, reports back pain, and difficulty moving the lower extremities. Which additional observation is an indication the patient may be experiencing neurogenic shock? A. Cool and pale skin B. Increased systolic blood pressure C. Poor skin turgor D. Bradycardia
D. Bradycardia
A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category? A. High urgent B. Urgent C. Non-urgent D. Emergent
D. Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Non-urgent conditions can wait for hours or even days. (High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time lapsing prior to treatment).
A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock? A. Hypertension. B. Bradycardia. C. Bounding pulse. D. Confusion.
D. Confusion Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia, and weak pulse. Cardiogenic shock is a serious complication of myocardial infarction with a high mortality rate
A patient is being treated for hemorrhagic shock secondary to multiple rib fractures and a lacerated liver. Two units of packed red blood cells have been administered. Which of these measurements is an indication the patient has received adequate volume replacement? A. Oxygen saturation 90% B. Increased serum creatinine C. Decreased right atrial pressure D. Decreased serum lactate
D. Decreased serum lactate
A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the family members that the patient can perform ADLs independently. b. remind the patient about the importance of independence in daily activities. c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities. d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents
D. Develop POC to increase independence
Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment? A. "After this treatment, my ears will not stick out." B. "The mask will help protect my skin from sun damage." C. "Using this mask will prevent scars from being permanent." D. "My facial scars should be less severe with the use of this mask."
D. Facial scars should be less severe The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not change the angle of ear attachment to the head.
A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury
D. Flaccid paralysis and lack of sensation
The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
D. Full thickness The characteristics of the wound meet the criteria for a full-thickness injury (color that is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm and inelastic).
What additional laboratory test should be performed on any African American client who sustains a serious burn injury? A. Total protein B. Tissue type antigens C. Prostate specific antigen D. Hemoglobin S electrophoresis
D. Hemoglobin S electrophoresis Sickle cell disease and sickle cell trait are more common among African Americans. Although clients with sickle cell disease usually know their status, the client with sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur in the emergent phase of a burn injury could result in decreased tissue perfusion that is sufficient to cause sickling of cells, even in a person who only has the trait. Determining the client's sickle cell status by checking the percentage of hemoglobin S is essential for any African American client who has a burn injury.
During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? A. Elevate the client's legs B. Put the client flat in bed C. Put the client in the Trendelenburg's position D. Put the client in the high-Fowler's position
D. High Fowler's position Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension. Elevating the client's legs, putting the client flat in bed, or putting the bed in the Trendelenburg's position places the client in positions that improve cerebral blood flow, worsening hypertension.
The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintain to retain maximum function of this joint? A. Hip maintained in 30-degree flexion, no knee flexion B. Hip flexed 90 degrees and knee flexed 90 degrees C. Hip, knee, and ankle all at maximum flexion D. Hip at zero flexion with leg flat
D. Hip at zero flexion with leg flat Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree of flexion
Which statement by the client indicates correct understanding of rehabilitation after burn injury? A. "I will never be fully recovered from the burn." B. "I am considered fully recovered when all the wounds are closed." C. "I will be fully recovered when I am able to perform all the activities I did before my injury." D. "I will be fully recovered when I achieve the highest possible level of functioning that I can."
D. I will achieve highest level of functioning Although a return to pre burn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning.
The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? A. Slow the IV infusion rate B. Administer dopamine C. No interventions are needed at this time D. Increase the IV infusion rate
D. Increase the IV infusion rate
During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? A. Increased wound pain 30 to 40 minutes after drug application B. Presence of small, pale pink bumps in the wound beds C. Decreased white blood cell count D. Increased serum creatinine level
D. Increased creatinine level Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored
A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? A. Absent corneal reflex B. Decerebrate posturing C. Movement of only the right or left half of the body D. The need for mechanical ventilation
D. Mechanical Ventilation The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. Absent corneal reflexes, decerebrate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries.
The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse's best action? A. Nothing, because the findings are normal for clients during the acute phase of recovery. B. Increase the temperature in the room and increase the IV infusion rate. C. Assess the client's airway and oxygen saturation. D. Notify the burn emergency team.
D. Notify burn emergency team These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? A. Headache B. Lumbar spinal cord injury C. Neurogenic shock D. Noxious stimuli
D. Noxious Stimuli Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause autonomic dysreflexia. A headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Neurogenic shock isn't a cause of dysreflexia.
In assessing the client's potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission? A. "Are you a smoker?" B. "When was your last chest x-ray?" C. "Have you ever had asthma or any other lung problem?" D. "In what exact place or space were you when you were burned?"
D. Place and space The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms. although smoking increases the risk for some problems, it does not predispose the client for an inhalation injury.
On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action? A. Documenting the findings B. Loosening any dressings on the chest C. Raising the head of the bed D. Preparing for intubation
D. Preparing for intubation Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway. The swelling usually precludes intubation.
The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is a. transfers independently to a wheelchair. b. drives a car with powered hand controls. c. turns and repositions self independently when in bed. d. pushes a manual wheelchair on flat, smooth surfaces
D. Pushes manual wheelchair
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? A. Place the client flat in bed B. Assess patency of the indwelling urinary catheter C. Give one SL nitroglycerin tablet D. Raise the head of the bed immediately to 90 degrees
D. Raise HOB 90 degrees Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia.
The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first? A. Applies silver sulfadiazine (Silvadene) ointment B. Covers the area with an elastic wrap C. Places a synthetic dressing over the area D. Removes loose nonviable tissue
D. Remove nonviable tissue All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process is removing exudates and necrotic tissue.
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment? A. Determine the level at which the patient has intact sensation. B. Assess the level at which the patient has retained mobility. C. Check blood pressure and pulse for signs of spinal shock. D. Monitor respiratory effort and oxygen saturation level
D. Respiratory The first priority for the patient with an SCI is assessing respiratory patterns and ensuring an adequate airway. The patient with a high cervical injury is at risk for respiratory compromise because the spinal nerves (C3 - 5) innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary, but not as high priority. Focus: Prioritization
The client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which is the nurse's best action? A. Continuing to monitor the client B. Increasing the temperature in the room C. Increasing the rate of the intravenous fluids D. Preparing to do a workup for sepsis
D. Sepsis These findings are associated with systemic gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing the temperature in the room may make the client more comfortable, but the priority is finding out if the client has sepsis and treating it before it becomes a shock situation. Increasing the rate of intravenous fluids may be done to replace fluid losses with diarrhea, but is not the priority action.
A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to a. advise the patient to talk to his wife to determine how she feels about his sexual function. b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury. c. inform the patient that most patients with upper motor neuron injuries have reflex erections. d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling
D. Sexual counseling
A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? A. "Clean the meatus from back to front." B. "Measure the quantity of urine." C. "Gently rotate the catheter during removal." D. "Clean the meatus with soap and water."
D. Soap and Water Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the urinary meatus. The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man. It isn't necessary to measure the urine. The catheter doesn't need to be rotated during removal.
The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: A. Keeping the client on a stretcher B. Logrolling the client on a firm mattress C. Logrolling the client on a soft mattress D. Placing the client on a Stryker frame
D. Stryker frame Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.
An infant was delivered to a mother with a diagnosis of chorioamnionitis. The infant is lethargic, tachypneic, and has an axillary temperature of 96.8. The healthcare provider suspects septic shock. Which of these assessments is an indication that this infant is compensating by increasing cardiac output? A. Active precordium B. Warm, flushed skin C. Bounding pulses D. Tachycardia
D. Tachycardia
A client with a C6 spinal injury would most likely have which of the following symptoms? A. Aphasia B. Hemiparesis C. Paraplegia D. Tetraplegia
D. Tetraplegia Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below.
It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first? A. An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade B. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed. C. A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed. D. A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
D. The homeless person has symptoms of heat stroke, a medical emergency, which increases risk for brain damage. Elderly patients are at risk for heat syncope and should be educated to rest in cool area and avoid future similar situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes fluids (IV or parenteral) and cooling measures. The prognosis for recovery is good.
An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to "drinking a few on the weekend." What is the priority nursing action for this patient? A. Obtain an order for a blood alcohol level. B. Contact the family to obtain additional history and baseline information. C. Administer naloxone (Narcan) 2 - 4 mg as ordered. D. Administer IV fluid support with supplemental thiamine as ordered
D. The patient presents with symptoms of alcohol abuse and there is a risk for Wernicke's syndrome, which is caused by a thiamine deficiency. Multiples drug abuse is not uncommon; however, there is nothing in the question that suggests an opiate overdose that requires naloxone. Additional information or the results of the blood alcohol level are part of the total treatment plan but should not delay the immediate treatment.
What are characteristics of the irreversible stage of shock? A. The worsening of tissue hypoperfusion and the onset of worsening circulatory and metabolic imbalances, including acidosis B. The body tries to initiate compensatory mechanisms C. Nothing can correct the hemodynamic defect D. Tissue and cell damage is too great tissue and necrosis of the tissue will occur even if the underlying hemodynamic defect is corrected
D. Tissue and cell damage is too great; tissue and necrosis of the tissue will occur even if the underlying hemodynamic defect is corrected
A client who was burned has crackles and a respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first? A. Administer digoxin B. Perform chest physiotherapy C. Monitor urine output D. Place the client in an upright position
D. Upright position Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in the upright position can relieve the lung congestion immediately before other measures can be carried out. Digoxin may be given later to increase cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid. Monitoring urine output is important. However it is not an immediate intervention.
What class of drug is typically used to treat neurogenic shock? A. Beta-blocker B. Calcium-channel blocker C. Loop diuretic D. Vasopressor
D. Vasporessor
Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D
D. Vitamin D Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in full thickness burns.
When admitting a patient who has a history of paraplegia as a result of a spinal cord injury, the nurse will plan to a. check the patient for urinary incontinence every 2 hours to maintain skin integrity. b. assist the patient to the toilet on a scheduled basis to help ensure bladder emptying. c. use intermittent catheterization on a regular schedule to avoid the risk of infection. d. ask the patient about the usual urinary pattern and measures used for bladder control
D. ask about usual urinary patterns
I'm no longer able to breathe on my own, my HR is erractic or I've gone in to asystole, my skin has become jaundiced, I'm anuric, become unresponsive and now have profound acidosis. What stage of shock
End-Organ
My BP is normal, HR >100, RR >20, skin is cold and clammy, slight decrease to urinary output, confused, and respiratory alkalosis. What stage of shock
Pre-Shock
My BP systolic BP <80-90, HR 100-150, rapid shallow respirations with crackles heard on auscultation, skin has become mottled with petechiae, urine output has become severely decreased, I'm lethargic and have gone in to metabolic acidosis. What stage of shock
Shock
