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Nurse is caring for a client who is in hypovolemic shock related to hemorrhage. The nurse prepares IV tubing to infuse with which IV solution in preparation for a blood transfusion?

0.9% sodium chloride

A client with 55% total body surface area burns arrives in the emergency department. The client weighs 160 #. Using the parkland burn formula calculate the hourly rate of lactate ringer during the first 8 hours of fluid resuscitation.

1000

The provider ordered dopamine 20mcg/kg/min IV infusion. The bag is labeled dopamine 100mg/50ml. the client weighs 88 #. What is the infusion rate in ml/hr?

24ml/hr

Burn client is brought into the emergency department with the following burns: half of the front torso, entire left arm, front of the left leg. The nurse should record the total body surface area burn as?

27%

Calculate the mean arterial pressure in mmHg for a client with a blood pressure of 84/46 mmHg.

59mmHg

Client with a possible spinal cord injury is admitted to the emergency department. Which finding by the nurse will help confirm a diagnosis of neurogenic shock?

Apical heart rate 48 beat/min

Which if the following interventions is not appropriate for a client diagnosed with a pneumothorax?

Apply wet dressing on wound

The nurse is caring for a client who suffered a third degree burn to his hands after a house fire. He presented with an airway injury secondary to smoke inhalation and has been intubated. The client is surrently on the ventilator with 100% FiO2. Based on the information, which of the following would be a sign or symptom of acute respiratory distress syndrome?

Arterial blood gas results show PaO2 50 mmhg

Nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?

Assess breath sounds every 4 hours

Nurse is caring for a client experiencing hypovolemic shock. Which of the following interventions would not be appropriate for this client?

Assist to a sitting position

Intensive care unit nurse is caring for a client. The ventilator alarms are sounding. Which interventions should the nurse implement first?

Auscultate the client's lung sounds

Client with neurogenic shock is receiving phenylephrine infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action?

Clients IV infusion site is cool and pale

Client presents with the following vital signs: blood pressure 90/60 mm hg, temperature 38.3 (101F), heart rate 116 beats/min, respiratory 24 breaths/min. the client has a post-op abdominal incision that is warm and red. Which type of shock is this client in?

Septic shock

A client is being treated for hypovolemic shock. As the nurse reassesses the client, which finding indicates the interventions are effective?

Serum lactate and serum potassium level are declining

Nurse is managing several IV medications to maintain the blood pressure of a client in hypovolemic shock. Which medication places the client at risk for a hypertensive reaction, requiring the nurse to assess the blood pressure at least every 15 minutes?

Sodium nitroprusside?

Which actions are essential for the nurse caring for a mechanically ventilated client to prevent ventricular acquired pneumonia?

- Perform oral care every 12 hours - Prevent aspiration - Suction every 1-2 hours around the clock

Nurse is planning care for an adult client who sustained severe burn injuries. Which interventions should the nurse include in the plan of care?

- limit visitors in the clients room when immunosuppressed - offer high calorie, high protein foods or supplemental feeding

Certified burn nurse is introducing a new nurse to the burn unit. The nurse is educating the new nurse on the degree staging of burns. Which of the following provides the correct description of a wound to the correct level of injury?

- Superficial thickness: reddened skin, desquamation, heals quickly without intervention - Superficial partial thickness: pink, moist, blanching, some blistering is involved -Deep partial thickness: blisters typically do not form, deep dermal injury, may need grafting - Full thickness: epidermal and dermal layers are destroyed, development of eschar

nurse is caring for a client in shock. The nurse understands that the client's sympathetic nervous system is still correctly attempting to compensate when the following is assessed?

- Client has an increased respiratory rate - Client has widening pulse pressure

Client has been diagnosed with pulmonary embolism. Which diagnostics and treatments does the nurse anticipate will be ordered?

- D Dimer - Thrombolytics - CT angiogram

A client with a pulmonary embolism may have which of the following interventions?

- Embolectomy - Heparin Drug therapy

An older adult client arrives in the emergency department after falling off a roof. The nurse observes "sucking inward" of the loose chest area during inspiration and a "puffing out" of the same area during expiration. Arterial blood gas results show severe hypoxemia and hypercarbia. Which procedure does the nurse prepare for?

- Endotracheal Intubation

client with neurogenic shock has just arrived in the emergency department after a diving accident. Ha has a cervical collar in place. Which of the following actions should the nurse take?

- Obtain baseline body temperature - Prepare for intubation and mechanical ventilation - Assist the client into semi fowlers position

A nurse is assessing four clients. Which of the following clients should the nurse assess first?

A client that has self extubated his endotracheal tube

A nurse is reviewing the health records of clients. Which client is at greatest risk for developing acute respiratory distress syndrome and multiple organ dysfunction syndrome?

A client who experienced anaphylactic shock

A nurse is reviewing the health records of clients. Which client is at least risk for developing acute respiratory distress syndrome? A client who experienced a near drowning incident in f

A client who has hemoglobin of 10.1 mg/dl post 1 unit PRBC

A nurse is caring for a group of clients. Which client is at most risk for a pulmonary embolism?

A long distance truck driver

A nurse is assessing a client who sustained superficial partial thickness and deep partial thickness burns 38 hours ago. Which finding should the nurse report to the provider?

ABG pH 7.31, PaCO2 37 mmHg, HCO3 31 mEq/L

Client arrived at the burn unit more than 2 weeks ago. The care plan for this client requires assistance by the nurse to perform daily range of motion exercises and help with mobility. The client tells the nurse he will no longer participate due to the pain it always causes. Which of the following should the nurse do next?

Acknowledge the clients concerns regarding pain and discuss how to promote his exercise plan in a way to have less pain but also allow therapeutic level of treatment

Nurse is planning care for a client who has severe acute respiratory distress syndrome (ARDS). Which actions should the nurse include?

Administer antiviral and antibiotics for every cause of ARDS

Client is treated in the emergency department for shock of unknown etiology. The first action by the nurse is which of the following?

Administer oxygen

Nurse is evaluating the lab values of a client who is in the resuscitation phase following a major burn. Which of the following lab findings should the nurse expect?

Albumin 2.9

When caring for a client who has early sepsis, which change in status is most important for the nurse to report to the health care provider?

Altered mental status

Nurse is caring for a client who is in the progressive stage of shock. Which finding should the nurse expect?

Blood pressure change from 129/78 (95) mm hg to 89/45 (60) mm hg

A nurse is caring for a client with arterial blood gas results pH 7.21, PaCO2 60 mmhg, PaO2 42 mmHg, HCO3 22mEq/L. which medication should the nurse prepare to administer?

Bronchodilator

A nurse is educating a new nurse on the different types of shock. The new nurse is asked to identify which client is not experiencing distributive shock?

Client with tension pneumothorax and cardiovascular compression

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 perform which of the following?

Call the healthcare provider to report the loss of the radial pulse

When assessing a client who has suffered a burn injury, the nurse classifies the burn as a full thickness burn based on observing which characteristics?

Charred skin with milky areas

Client has been prescribed silver sulfadiazine for a burn injury. Which of the following findings would give the nurse reason to question the order for this topical burn cream?

Client has a sulfa allergy listed on the chart

Which information about a client receiving dobutamine to treat septic shock is most important for the nurse to communicate to health care provider?

Client is complaining of chest pain

A client who has an endotracheal tube is being considered for a tracheostomy. Which of the following criteria would support the placement of a tracheostomy in this client?

Client is unable to maintain airway when extubated

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation. Which statement indicates the nurses correct understanding of DIC?

DIC is caused by abnormal coagulation involving fibrinogen

When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicated a need for further education in the care of clients with shock?

Decreasing the room temperature to 68 F for a patient with neurogenic shock

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of pneumothorax in this client?

Diminished breath sounds

Nurse is caring for a client being treated with mechanical ventilation. The ventilator sounds a low pressure alarm. The nurse immediately assess for other signs of which condition?

Disconnected endotracheal tube

The nurse is caring for a ventilated client. Which intervention is appropriate for this client?

Ensure there is a manual resuscitation bag at the bedside

Client presented to the ED after receiving second and third degree burns from a kitchen grease spill. The tops of both thighs, the groin area, and lower abdomen were the areas of injury. About 3 hours after the injury, the client begins to decompensate and is being prepped for intubation. Regarding the change in client status, which explanation by the nurse is correct when educating the clients family?

Even a burn as little as 25% of the body can cause a systemic response, requiring emergency management

A client begins to show signs of shock. How should the client be positioned?

Flat with legs elevated

A client with septic shock has a urine output of 20ml/hr for the past 3 hours. The pulse rate is 120 beats/min, and the venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question?

Give furosemide

After receiving report of four client, the nurse determines the order of care of the clients. Based on report, the nurse will prioritize the clients to see which one first?

Healthy 18 year old with rapid shallow respirations

A nurse is assessing a client who has fluid volume overload from cardiogenic shock. Which manifestation of cardiogenic shock should the nurse expect?

Heart rate 121 beats/min

A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching?

I will be on special shower table to enhance wound inspection and debridement

A client is receiving warfarin after pulmonary embolism. The nurse evaluates the lab results and notifies the physician that the clients warfarin level is therapeutic when which of the following numbers is reported?

INR 2.8

Postop client reports a sudden onset of shortness of breath and pleuritic chest pain. Assessment findings include diaphoresis, hypotension, crackles in the left lower lobe and pulse oximetry of 85% on room air. What does the nurse suspect has occurred with this client?

Pulmonary embolism

The pathophysiology of acute respiratory distress syndrome is characterized by which of the following?

Refractory hypoxemia

The nurse is developing a care plan for a client in the acute phase of a burn injury. Which of the following would be the priority nursing diagnosis for this client?

Risk for infection related to slow healing graft donor site

The client, who is 2 days postoperative following a pneumonectomy, has an apical pulse rate of 128 beats/min and a blood pressure of 80/50 mmhg. Which intervention should the nurse implement first?

Increase the clients IV rate as ordered

A client is being treated for distributive shock with IV norepinephrine. The nurse expects the drug to have which effect on the clients mean arterial pressure?

Increased MAP with no change in vascular volume

Client with shock of unknown etiology whose hemodynamic monitoring indicates a blood pressure of 92/54 mm hg, pulse 64 beats/min, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question?

Infuse saline at 250 ml/hr

A nurse is caring for a client who has sustained burns over 37% of total body surface area. The client's voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following?

Inhalation injury

A nurse in a burn treatment center is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Whish nursing statement is appropriate?

Large, surgical incision will be made in the hardened dermal layer to improve circulation

Which of these findings is the best indicator that the fluid resuscitation for a client with hypovolemic shock has been successful?

Mean arterial pressure is 65 mm hg

Which intervention will the nurse include in the plan of care for a client who has cardiogenic shock?

Monitor breath sounds frequently

A client in the intensive care unit was recovering from moderate burns and smoke inhalation. His condition was improving, and plans were made to transfer him to a step- down unit. On the morning of the transfer, the client began to experience elevated temperatures and shortness of breath. Urine output decreased to 10ml/hr. labs were drawn and indicated elevated WBC, GFR, creatinine, and liver enzymes. The client is experiencing which medical complication?

Multiple organ dysfunction syndrome

During change of shift report, the nurse learns that a client has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider?

New onset of confusion and agitation

Client who is one day post-op following chest surgery, is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first?

Notify the rapid response team

Which assessment is important for the nurse to evaluate whether the treatment of a client with anaphylactic shock has been effective?

Oxygen saturation

Nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

Pain, especially with inspiration

Client with a chest injury has suffered a flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

Paradoxical chest movement

A client in respiratory failure is diagnosed with a flail chest. After the client is intubated, which treatment does the nurse expect to be implemented?

Positive end expiratory pressure (PEEP)

A nurse is assisting the provider in caring for a client who has developed a tension pneumothorax. Which actions should be performed first?

Prepare for large bore needle thoracostomy

Nurse recognizes indication of respiratory distress includes all the following except?

Stridor

A nurse is assessing the fluid status of a client being treated for a burn during the emergent phase. Which of the following is an indicator of adequate fluid resuscitation?

Urine output at least 30 ml/hr

When assessing a client who is severely bleeding and at risk for hypovolemic shock, the nurse anticipates which of the following?

Weak, thready pulse

Nurse is caring for a client who is in the nonprogressive compensatory stage of hypovolemic shock. Which finding should the nurse anticipate?

decrease in mean arterial pressure MAP by 20 points form baseline