shocks/burns -APRIL 20
A client with burns to 40% of the body arrives at the emergency room. Which prescriptions by the primary healthcare provider should the nurse anticipate? Select all that apply. Insertion of a nasogastric tube Education about the importance of good nutrition Administration of lactated Ringer's (LR) solution intravenously Monitoring the client's body temperature Administration of 100% humidified oxygen
Insertion of a nasogastric tube Administration of 100% humidified oxygen Monitoring the client's body temperature Administration of lactated Ringer's (LR) solution intravenously Explanation: A client arriving to the emergency room with burns is in the emergent/resuscitative phase of managing a burn injury. The nurse should expect the primary healthcare provider to prescribe insertion of a nasogastric tube to decompress the stomach and prevent vomiting. Administration of 100% humidified oxygen and monitoring the client's body temperature are also expected. Fluid resuscitation for clients with burn injuries greater than 20% is necessary to support circulatory function and tissue perfusion. Administration of LR intravenously is the preferred fluid. The nurse would not provide education about nutrition during the emergent phase.
There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) a 20-year-old who inhaled the smoke of the fire a 30-year-old with second-degree burns on the back of the left leg (about 9% of body surface area (BSA) a 40-year-old with second-degree burns on the right arm (about 10% of BSA) a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA)
an 8-year-old with third-degree burns over 10% of the body surface area (BSA) a 20-year-old who inhaled the smoke of the fire a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) Explanation: Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.
The nurse is caring for a teenage client on a burn unit who has sustained third-degree burns over 40% of the body. A family member asks why the client isn't reporting of more pain. Which of the following is the best response by the nurse? "The severe burns have damaged nerves that sense pain." "The burns are not deep enough to cause much pain." "The client is confused and can't verbalize a pain rating." "The pain medication is working adequately." SUBMIT ANSWER Exit quiz
"The severe burns have damaged nerves that sense pain." Explanation: Full-thickness burns damage nerve endings and initially may feel somewhat painless. Regeneration of the nerve endings in recovery may cause significant pain. Confusion, adequate pain medication, and burns that are not deep enough would not be the most likely explanation of the client's lack of reports of pain.
A nurse is assessing a client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg, and on admission to the postsurgical nursing unit it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. After determining that other vital signs are normal, what should the nurse do first? Check the intake and output record. Notify the health care provider (HCP). Elevate the head of the bed. Administer pain medication. SUBMIT ANSWER Exit
Notify the health care provider (HCP). Explanation: The client's systolic blood pressure is dropping, and the pulse pressure is narrowing, indicating impending shock. The nurse should notify the surgeon. Elevating the head of the bed will not increase the blood pressure. Administering pain medication could cause the blood pressure to drop further. The intake and output record may indicate decreased urine output related to shock, but the nurse should first contact the HCP.
The nurse should assess a client for which of the following complications associated with disseminated intravascular coagulation (DIC)? Renal calculi Septic shock Congestive heart failure Pulmonary embolism SUBMIT ANSWER Exit quiz
Pulmonary embolism Explanation: Pulmonary embolism is an indication of intravascular clotting due to the fact that platelets have been significantly decreased and there is clotting and bleeding. Low prothrombin levels will also show that there is a delay in clotting, so the person will bleed for a longer time. The other conditions are not associated with DIC.
A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to infection Related to fat emboli Related to circumferential eschar Related to femoral artery occlusion
Related to circumferential eschar Explanation: As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.
The nurse is performing triage in the emergency department. Which client should be seen first? The client with burns to his chest and neck with singed nasal hair. A primipara who is 39 weeks pregnant having contractions every 15 minutes. The client who has an open fracture of his radius. The client with flank pain.
The client with burns to his chest and neck with singed nasal hair. Explanation: The client with burns to the chest and neck has the potential to develop decreased lung expansion. Singed nasal hair is indicative of inhalation injury and delayed respiratory distress syndrome. Flank pain and open fractures will not take precedence over the client with airway problems. The primipara still has time before the baby comes.
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: blood pressure. temperature. heart rate. hemoglobin level.
blood pressure. Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.
Which indicates hypovolemic shock in a client who has had a 15% blood loss? respiratory rate of 4 breaths/minute pulse rate less than 60 bpm systolic blood pressure less than 90 mm Hg pupils unequally dilated
systolic blood pressure less than 90 mm Hg Explanation: Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury.
The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which change on the client's chart to the health care provider (HCP)? urine output respiratory rate heart rate blood pressure
urine output Explanation: Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. The other changes in vital signs on the client's chart are not as significant as the decreased urinary output.
Which of the following statements indicate that a family member of a client in cardiogenic shock understands the need for an intra-aortic balloon pump? "This device increases how hard the heart has to work." "This device decreases the heart's need for oxygen." "This device decreases the blood flow in the heart." "This device helps stop life-threatening heart rhythms." SUBMIT ANSWER
"This device decreases the heart's need for oxygen." Explanation: An intra-aortic balloon pump increases coronary perfusion and cardiac output, and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock. A defibrillator is commonly used for termination of life-threatening ventricular rhythms.
The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? A Sa02 reading is 92% A urinary output of 50 mL in the past 3 hours Vital signs T 38° C (100.4° F), P 104, R 26 and B/P 100/60 A white blood cell count of 19,000mm3 SUBMIT ANSWER
A urinary output of 50 mL in the past 3 hours Explanation: Sepsis can cause the release of myoglobin from the cells which will directly block the renal tubules causing decreased urinary output. If it is not treated with hydration and antibiotics, the client could develop renal failure. A high white blood cell count is expected with sepsis. Temperature can be elevated or below normal, in clients with sepsis. The elevated pulse and respirations are normal in the presence of infection and should be monitored. The saturated oxygen level is within normal limits as is the blood pressure.
The nurse is caring for a 70-year-old male client after a colectomy. The client has received chemotherapy prior to surgery and has hypertension and diabetes mellitus. Which factors put this client at risk for sepsis? Select all that apply. weight diabetes mellitus abdominal surgery age gender
age abdominal surgery diabetes mellitus Explanation: Known risk factors for sepsis include age (<1 year and >65 years old), chronic illness, and invasive procedures. Immunosuppression and malnourishment are also risk factors. There is no correlation between gender or age and risk for sepsis. Nurses must be aware of risk factors and monitor clients at risk closely for any signs of sepsis.
Which nursing intervention would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? teaching cigarette smoking cessation monitoring clients for signs of hypercapnia maintaining adequate serum potassium levels replacing fluids adequately during hypovolemic states
replacing fluids adequately during hypovolemic states Explanation: One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.
A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number. ? percent
36 Explanation: The anterior and posterior portion of one leg is 18%. If both legs are burned, the total is 36%.
What is the primary goal for the care of a client who is in shock? Maintain adequate vascular tone. Achieve adequate tissue perfusion. Prevent hypostatic pneumonia. Preserve renal function.
Achieve adequate tissue perfusion. Explanation: A primary outcome for the care of the client in shock is to achieve adequate tissue perfusion, thus avoiding multiple organ dysfunction. The lungs are susceptible to injury, especially acute respiratory distress syndrome. Vasoconstriction occurs as a compensatory mechanism until the client enters the irreversible stage of shock.
The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock? Enalapril Dopamine Metoprolol Furosemide
Dopamine Explanation: Cardiogenic shock is when the heart has been significantly damaged and is unable to supply enough blood to the organs of the body. Dopamine, a sympathomimetic drug, improves myocardial contractility and blood flow through vital organs by increasing perfusion pressure. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and does not have a direct effect on contractility or tissue perfusion. Metoprolol is a adrenergic blocker that slows heart rate and lowers blood pressure; neither is a desired effect in the treatment of cardiogenic shock.
The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which finding? Select all that apply. thirst widening pulse pressure dry, flushed skin tachycardia rapid respirations decreased urine output
decreased urine output tachycardia rapid respirations thirst Explanation: The client who is experiencing upper GI bleeding is at risk for developing hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to find are those related to hypovolemia, including decreased urine output, tachycardia, rapid respirations, and thirst. The client's skin would be cool and clammy, not dry and flushed. The client would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a widening pulse pressure. Remediation
A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? Seizures Shock Stroke Hyperglycemia
Shock Explanation: Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren't associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.
The nurse anticipates the transfer of which of the following burn clients to a burn center? Select all that apply. A child with burns of hands and feet A child with 15% TBSA second-degree burns on torso An adult with an electrical burn An adult with 1.5% total body surface area (TBSA) third-degree burns of face An adult with 20% TBSA second-degree burns on lower extremities
An adult with 1.5% total body surface area (TBSA) third-degree burns of face An adult with an electrical burn A child with burns of hands and feet Explanation: Major burn injuries include second-degree burns > 25% in adults or > 20% in children, any electrical injuries, and any burns involving eyes, ears, face, hands, feet, perineum, and joints.
The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? Red blood cells (RBCs) and hemoglobin count findings White blood cell differential Oxygen saturation level Arterial blood gas (ABG) findings
Arterial blood gas (ABG) findings Explanation: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Oxygen saturation levels are usually affected by hypoxemia but cannot be used to diagnose acid-base imbalances such as metabolic acidosis.
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? Normal saline solution with 20 mEq of potassium per 1,000 ml Lactated Ringer's solution Dextrose 5% in water (D5W) Albumin
Lactated Ringer's solution Explanation: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.
Which finding is a risk factor for hypovolemic shock? gram-negative bacteria vasodilation hemorrhage antigen-antibody reaction
hemorrhage Explanation: Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock.
An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply. the victim with chemical spills on both arms the victim who inhaled smoke the victim in respiratory distress the victim with third-degree burns of both legs the victim with first-degree burns of both hands
the victim with chemical spills on both arms the victim with third-degree burns of both legs the victim in respiratory distress the victim who inhaled smoke Explanation: Victims with chemical burns, second- and third-degree burns over more than 20% of their body surface area, and those with inhalation injuries should be transported to a burn center. The victim with first-degree burns of the hands can be treated with first aid on the scene and referred to a health care facility.
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first? Administer the antidote for penicillin, as ordered, and continue to monitor the client's vital signs. Prepare to administer a corticosteroid IV. Administer epinephrine, as ordered, and prepare to intubate the client, if necessary. Insert an indwelling urinary catheter and begin to infuse I.V. fluids, as ordered.
Administer epinephrine, as ordered, and prepare to intubate the client, if necessary. Explanation: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator, as ordered. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications do not relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists. However, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring. However, administering epinephrine is the first priority.
A client is experiencing hypovolemic shock. Which of the following assessments best assists in evaluating the client's fluid status? Select all that apply. Respiratory rate Skin turgor Daily weight Heart rate Hemoglobin level Blood pressure
Blood pressure Heart rate Respiratory rate Skin turgor Daily weight Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. As compensatory mechanisms, heart and respiratory rates generally increase with both fluid volume deficit and overload, making those assessment essential. Skin turgor and daily weights are essential assessments in the client with any fluid imbalance. The hemoglobin level reflects red blood cell concentration, not overall fluid status.
The nurse is aware that, in addition to the rule of nines, which is the most important assessment priority when assessing a client with facial burns? Observing for facial swelling and disfiguration Assessing tolerance of the pain Checking for airway patency Determining oxygen saturation levels SUBMIT ANSWER Exit quiz
Checking for airway patency Explanation: Because the client has received facial burns, there may have been gasping for air resulting in a steam inhalation. The consequence is that the resultant inflammation and swelling may result in airway impairment. The other assessments are not as critical as airway patency.
A client with septic shock has continued to deteriorate and has become unresponsive. The nurse has inserted an intravenous line and an oral airway. Which of the following is the highest priority for the nurse at this time? Check the surgical dressing to ensure that it is intact. Monitor temperature every 4 hours. Examine the IV site for infiltration. Confirm the placement of the oral airway. SUBMIT ANSWER Exit quiz
Confirm the placement of the oral airway. Explanation: Confirming the placement of the oral airway ensures a patent air passage. Oxygen is essential for life, so this action takes priority. Other answers do not reflect ABC priority based on client unresponsiveness.
A nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage? Heart rate 120 beats/minute, respiratory rate 8 breaths/minute, blood pressure 150/100 mm Hg Heart rate 50 beats/minute, respiratory rate 8 breaths/minute, blood pressure 150/100 mm Hg Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg Heart rate 50 beats/minute, respiratory rate 28 breaths/minute, blood pressure 150/100 mm Hg
Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg Explanation: An increased heart rate (usually greater than 100 beats/minute, depending on the client's baseline) followed by an increased respiratory rate and decreased blood pressure may be the first signs of postpartum hemorrhage and hypovolemic shock. Remediation:
The priority nursing diagnosis for a client who has just been admitted to the hospital with burns would be which of the following? Impaired skin integrity Risk for altered nutrition Body image disturbance Impaired social interaction SUBMIT ANSWER Exit quiz
Impaired skin integrity Explanation: Impaired skin integrity is the priority in the situation of the burned client because of the fluid and electrolyte loss and a high risk for infection. While body image, social interaction, and altered nutrition are all concerns, they are not necessarily potentially life threatening, unlike the impaired skin integrity.
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? 10% dextrose in water Half-normal saline solution Lactated Ringer's solution 5% dextrose and normal saline solution
Lactated Ringer's solution Explanation: Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.
A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority? Preparing for an escharotomy Preventing contractures of extremities Beginning range of motion exercises Replacing fluid and electrolytes SUBMIT ANSWER
Replacing fluid and electrolytes Explanation: After establishing a patent airway, fluid resuscitation is critical for the client with a burn injury. Positioning to prevent contractures and removing dead skin (escarotomy) are important interventions, but are not the priority. It is too soon to begin range of motion exercises.
Which finding is an indication of a complication of septic shock? acute respiratory distress syndrome (ARDS) chronic obstructive pulmonary disease (COPD) mitral valve prolapse anaphylaxis
acute respiratory distress syndrome (ARDS) Explanation: ARDS is a complication associated with septic shock. ARDS causes respiratory failure and may lead to death, even after the client has recovered from shock. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruction of bronchial airflow and involves chronic bronchitis and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction.
At about one-half hour before the daily whirlpool bath and dressing change the nurse should: soak the dressing. remove the dressing. administer an analgesic. slit the dressing with blunt scissors.
administer an analgesic. Explanation: Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.
The nurse is assessing a client with irreversible shock. The nurse should document which finding? diuresis hypertension circulatory collapse increased alertness
circulatory collapse Explanation: Severe hypoperfusion to all vital organs results in failure of the vital functions and then circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms associated with irreversible shock. The client in irreversible shock will not be alert.
Which is characteristic of cardiogenic shock? decreased myocardial contractility increased cardiac output hypovolemia infarction
decreased myocardial contractility Explanation: Cardiogenic shock occurs when myocardial contractility decreases and cardiac output greatly decreases. The circulating blood volume is within normal limits or increased. Infarction is not always the cause of cardiogenic shock.
A teenage client is admitted to the burn unit with burns over 49% of the body surface area, including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused, with reports of minor pain. When assessing the client, which of the following is an immediate priority for the nurse to evaluate? Mental status changes Reports of pain Patency of airway Emotional reaction to the fire
patency of airway Explanation: It is very likely that the client has had a smoke inhalation injury after suffering a severe burn greater than 20% of the total body surface area and having burns of the face and neck. The carbon particles observed around the nose and mouth would support this. Smoke inhalation can cause severe injury to the upper airway and lead to death. The other options would be secondary to evaluating the airway.
Which finding alerts the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago? urine output of 180 mL during the past 3 hours increased blood pressure and decreased pulse and respiratory rates restlessness and shortness of breath sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours
restlessness and shortness of breath Explanation: Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding. Increased blood pressure and decreased pulse and respiratory rates are classic late signs of increased intracranial pressure. Decreasing blood pressure and increasing pulse and respiratory rates occur with hypovolemic shock. Sanguineous drainage that changes to serosanguineous drainage at a rate less than 100 mL/h is normal in the early postoperative period. Urine output of 180 mL over the past 3 hours indicates normal kidney perfusion.
Which condition can place a client at risk for acute respiratory distress syndrome (ARDS)? chronic obstructive pulmonary disease heart failure septic shock asthma
septic shock Explanation: The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.
When assessing a client for early septic shock, the nurse should assess the client for which finding? warm, flushed skin hemorrhage increased blood pressure cool, clammy skin
warm, flushed skin Explanation: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.
A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. The nurse should base the response on the knowledge that there was: an obstruction of urine flow from the kidneys. a decrease in the blood flow through the kidneys. structural damage to the kidney resulting in acute tubular necrosis. a blood clot formed in the kidneys.
a decrease in the blood flow through the kidneys. Explanation: There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.
A client is admitted to the Emergency Department with a full thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should: call the health care provider (HCP) to report the loss of the radial pulse. continue to assess the arm every hour for any additional changes. administer morphine sulfate IV push for the severe pain. instruct the client to exercise his fingers and wrist.
call the health care provider (HCP) to report the loss of the radial pulse. Explanation: Circulation can be impaired by circumferential burns and edema, causing compartment syndrome. Early recognition and treatment of impaired blood supply is key. The HCP should be informed since an escharotomy (incision through full-thickness eschar) is frequently performed to restore circulation. Pain management is important for burn clients, but restoration of circulation is the priority. Assessments should be performed every 15 minutes while there is absence of the radial pulse. Exercise will not restore the obstructed circulation.
A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? "A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" "A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" "Generally caused by decreased blood volume" "It is due to severe hypersensitivity reaction resulting in massive systemic vasodilation."
"A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" Explanation: Shock may have different causes (e.g., hypovolemia, cardiogenic, septic), but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Movement of plasma into the interstitial spaces could reflect dependent edema and sepsis. Decreased blood volume is an example of hypovolemia. A hypersensitivity reaction is an example of anaphylactic shock or distributive shock.
A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? Record your answer as a whole number. ? mL/hour
250 Explanation: 2,000 mL/8 hours = 250 mL/hour
A client with sepsis and hypotension is being treated with dopamine. The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine in 250 ml, the infusion pump is running at 23 ml/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using two decimal places. ? mcg/ml/minute
7.71 Explanation: First, calculate how many micrograms per milliliter of dopamine are in the bag: 400 mg/250 ml = 1.6 mg/ml Next, convert milligrams to micrograms: 1.6 mg/ml × 1,000 mcg/mg = 1,600 mcg/ml Lastly, calculate the dose: 1,600 mcg/ml × 23 ml/hour/79.5 kg 79.5 kg/60 minutes/hour = 7.71 mcg/kg/minute
A postoperative client has exhibited decreased urine output, hypotension, and tachycardia. Which of the following is the priority nursing assessment? Check the dressing Assess IV rate Palpate the radial pulse Obtain bladder scan
Check the dressing Explanation: Although all are assessments that may be indicated for this client, and the priority is the dressing. The client is exhibiting signs of shock. Shock in a postoperative client typically results from bleeding.
A client presents to the ED in shock. During what phase of shock does the nurse know that metabolic acidosis is going to most likely occur? Compensation Decompensation Irreversible Early
Decompensation Explanation: The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals Into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis.
A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about? Urinary output of 190 milliliters and dark amber urine in 6 hours Dressing saturated with a moderate amount of bloody drainage, and blood pressure of 130/70 mm Hg Reports of pain and an occasional premature ventricular contraction (PVC) Heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 SUBMIT ANSWER Exit quiz
Heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 Explanation: The nurse should check for bleeding, monitor the vital signs, and promote urine output after airway patency has been established. Option D indicates the early signs and symptoms of shock and the nurse should be most conern.
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? Impaired physical mobility related to the disease process Ineffective airway clearance related to edema of the respiratory passages Impaired skin integrity related to disease process Risk for infection related to breaks in the skin
Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process is not appropriate because burns are not a disease. Impaired skin integrity related to disease process is not the priority and Risk for infection related to breaks in the skin may be appropriate, but they do not command a higher priority than Ineffective airway clearance because they do not reflect immediately life-threatening problems.
What is the most important goal of nursing care for a client who is in shock? Manage increased cardiac output. Manage fluid overload. Manage vasoconstriction of vascular beds. Manage inadequate tissue perfusion.
Manage inadequate tissue perfusion. Explanation: Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: increase the amount of scarring. decrease circulation to the fingers. increase edema in the arms. dislodge the autografts.
dislodge the autografts. Explanation: Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.
A client is in hypovolemic shock. In which position should the nurse place the client? supine supine with the legs elevated 15 degrees Trendelenburg's semi-Fowler's.
supine with the legs elevated 15 degrees Explanation: A client in hypovolemic shock is best positioned supine in bed with the feet elevated 15 degrees to bring peripheral blood into the central circulation. Neither semi-Fowler's position nor the supine position by itself promotes venous return. Semi-Fowler's position would not facilitate venous return. Trendelenburg's position inhibits respiratory expansion and possibly causes increased intracranial pressure.
Which client is at greatest risk for inadequate nutrition? the client who is breastfeeding the client with burns to 45% of the body the client recovering from a femur fracture the client with diabetetic peripheral neuropathy
the client with burns to 45% of the body Explanation: With illness or injury, there is a need to heal or recover. To accomplish this, the client must consistently consume adequate nutrition (and protein) to maintain a positive nitrogen balance, and to experience necessary growth and/or healing. The client with burns has the greatest nutritional needs, due to the extent of the injury. Clients with diabetic neuropathy can be encouraged to follow the diabetic diet plan and manage pharmacological therapy to prevent further neuropathy. The client with a fractured femur is not at risk for inadequate nutrition unless there is also a reason the client is not eating. The client who is breastfeeding needs additional calories, but if the client is eating a well-balanced diet with additional calories, the client is not at risk for obtaining inadequate nutrition.
A client is in the compensatory stage of shock. Which finding indicates the client is entering the progressive stage of shock? heart rate of 110 bpm temperature of 99° F blood pressure of 110/70 mm Hg urinary output of 20 ml per hour
urinary output of 20 ml per hour Explanation: In the compensatory stage of shock, the client exhibits moderate tachycardia, but as the shock continues to the progressive stage the client will have a decreased urinary output, hypotension, and mental confusion as a result of failure to perfuse and ineffective compensatory mechanisms. The body temperature initially may remain normal. These findings are indications that the body's compensatory mechanisms are failing.
A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? pulse rate of 112 bpm serum sodium level of 136 mEq/L (136 mmol/L) urine output of 30 mL/h blood pressure of 94/64 mm Hg
urine output of 30 mL/h Explanation: Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.
A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because: the client shows signs of aneurysm rupture. the client is experiencing heart failure. the client is going into cardiogenic shock. the client is in the early stage of right-sided heart failure.
the client is going into cardiogenic shock. Explanation: This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.
A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy? Providing emotional support to the client and family Maintaining the client's fluid and electrolyte balance Maintaining a caloric intake to meet metabolic needs Providing adequate management of pain
Maintaining the client's fluid and electrolyte balance Explanation: After maintaining respirations, the most important and immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Although caloric intake is important for healing, it is not the priority. Pain control and emotional support are also a lower priority than physiological needs.
A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding? decreased PaCO2 tachycardia bradycardia narrowed pulse pressure
tachycardia Explanation: The nurse should assess the client who is bleeding for tachycardia because the heart beats faster to compensate for decreased circulating volume and decreased numbers of oxygen-carrying red blood cells (RBCs). The degree of cardiopulmonary distress and anemia will be related to the amount of hemorrhage that occurred and the period of time over which it occurred. Bradycardia is a late symptom of hemorrhage; it occurs after the client is no longer able to compromise and is debilitating further into shock. If bradycardia is left untreated, the client will die from cardiovascular collapse. Decreased PaCO2 is a late symptom of hemorrhage, after transport of oxygen to the tissue has been affected. A narrowed pulse pressure is not an early sign of hemorrhage.
A client is receiving dopamine hydrochloride for treatment of shock. What action should the nurse take? Monitor blood pressure continuously. Administer pain medication concurrently. Monitor for signs of infection. Evaluate arterial blood gases at least every 2 hours.
Monitor blood pressure continuously. Explanation: The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acid-base balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infection is not related to the nursing action for the client receiving dopamine hydrochloride.
The student nurse asks why a client is receiving an IV of lactated Ringer's with potassium following an episode of diabetic ketoacidosis. What is the best response by the nurse? Hypokalemia is associated with uncontrolled diabetes, and the lactated Ringer's is isotonic fluid replacement. Lactated Ringer's will help lower the blood pH when hypokalemia is related to ketoacidosis. With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves. In acidosis, the sodium moves into the cells to buffer the acid and displaces the potassium. The lactated Ringer's helps restore the alkaline pH.
With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves. Explanation: In diabetic ketoacidosis, the cellular buffers will be activated. Potassium will move out of the cell and hydrogen will move inside the cells to lessen the impact on the plasma pH. Once the acidosis is corrected by bicarbonate injections and IV lactated Ringer's, potassium will move back into the cells, resulting in hypokalemia. Potassium levels will be monitored closely, and replacement will be initiated. Lactated Ringer's helps increase the blood pH and provides a source of bicarbonate replacement to replenish the base portion of the 1:20 acid-to-base relationship that helps maintain the blood at the pH of 7.35 to 7.45. Sodium does not switch with potassium in an acidotic state.
The nurse is assessing a client who is in shock. Which neurologic change indicates that the client is in the progressive stage of shock? unconsciousness incoherent speech confusion restlessness SUBMIT ANSWER
confusion Explanation: In the progressive stage of shock, the client can display listlessness or agitation, confusion, and slowed speech. Restlessness occurs in the compensatory stage. Incoherent speech and unconsciousness are clinical manifestations of the irreversible stage.
A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, his vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply. Cleaning the burns with hydrogen peroxide Placing ice directly on the burn areas Administering tetanus prophylaxis as ordered Administering 6 mg of morphine I.V. Starting an I.V. infusion of lactated Ringer's solution Covering the burns with saline-soaked towels
Starting an I.V. infusion of lactated Ringer's solution Administering 6 mg of morphine I.V. Administering tetanus prophylaxis as ordered Explanation: The goal of immediate interventions for this client should be to stop the burning and relieve the pain. To prevent hypovolemic shock and maintain cardiac output, the nurse should begin I.V. therapy with a crystalloid such as lactated Ringer's solution. To treat pain, she should administer 2 to 25 mg of morphine or 5 to 15 mg of meperidine I.V. in small increments. The nurse should also administer tetanus prophylaxis as ordered. Hydrogen peroxide and povidone-iodine solution could cause further damage to tissue, and saline-soaked towels could lead to hypothermia. Placing ice directly on burn wounds could cause further thermal damage.
Which clients with burns will most likely require an endotracheal or tracheostomy tube? A client who has: electrical burns of the hands and arms causing arrhythmias. secondhand smoke inhalation. chemical burns on the chest and abdomen. thermal burns to the head, face, and airway resulting in hypoxia
thermal burns to the head, face, and airway resulting in hypoxia. Explanation: Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.
