3421 Adults II Mod 7 - Shock, Sepsis, MODS, and Burns
A client weighing 160.2 pounds (72.7 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss? 156.0 lbs (70.8 kg) 157.0 lbs (71.2 kg) 158.0 lbs (71.7 kg) 159.0 lbs (72.1 kg)
158.0 lbs (71.7 kg) Remember to convert lb to kg! 1,000mL = 1kg = 2.2lbs 160.2 - 2.2 = 158.0
A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client? 110 mEq/L 130 mEq/L 145 mEq/L 165 mEq/L
165 mEq/L Symptoms of hypernatremia. Think putting salt in your mouth makes your tongue dry.
Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? Increased ability to stretch arm over the head Difficulty lying on affected side Pain worse in the morning Minimal pain with movement
Difficulty lying on affected side Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head.
The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? Electrical burns usually follow an internal path. Lightning is higher in voltage than electricity. The skin is a good conductor of electricity. Moisture intensifies the damage inflicted.
Electrical burns usually follow an internal path. Electrical current follows the path of less resistance. Because the skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way.
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: Epidermal layer only. Epidermis and a portion of deeper dermis. Entire dermis and subcutaneous tissue. Dermis and connective tissue.
Epidermis and a portion of deeper dermis. A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis.
A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client: Prevent infection Fluid resuscitation Endotracheal tube placement Strict intake and output
Fluid resuscitation Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA.
Which type of burn injury requires skin grafting? Full-thickness Superficial Superficial partial-thickness Deep partial-thickness
Full-thickness A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? Full-thickness Superficial Superficial partial-thickness Deep partial-thickness
Full-thickness I: A superficial burn only damages the epidermis. II: In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. III: A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry. IV: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone.
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? Head injury Myocardial infarction Diabetes Multiple sclerosis
Head injury If there is a bleed in or around the brain, this would increase blood flow to the bleed
The nurse is monitoring a patient who sustained a fracture of the left hip. The nurse should be aware that which kind of shock can be a complication of this type of injury? Cardiogenic Hypovolemic Neurogenic Septic
Hypovolemic In a client with a pelvic fracture, there is potential for hypovolemic shock resulting from hemorrhage.
The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? Classification by the appearance of blisters Identification by the destruction of the dermis and epidermis Not associated with edema formation Usually very painful because of exposed nerve endings
Identification by the destruction of the dermis and epidermis Third-degree (full-thickness) burns involve total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue.
Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture? Comminuted Compression Impacted Greenstick
Impacted Impacted fracture = a bone fragment is driven into another bone fragment. (wisdom teeth) Comminuted fracture = the bone has splintered into several fragments. Compression fracture = bone has been compressed. Greenstick fracture = one side of the bone is broken and the other side is bent.
A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: Jugular venous distention Decreased pulse rate to 110 beats/minute Positive increase in the fluid balance ratio Vesicular breath sounds
Jugular venous distention Monitor the client for cardiovascular overload, signs of difficulty breathing, pulmonary edema, and jugular vein distention. Decreased pulse rate, when the client is tachycardic as in hypovolemic shock, would indicate improvement. The client would also exhibit a positive increase in the fluid balance ratio when responding appropriately to treatment. Vesicular breath sounds are normal ones.
Which of the following is the preferred IV fluid for burn resuscitation? Lactated Ringer's (LR) Normal saline (NS) D5W Total parenteral nutrition (TPN)
Lactated Ringer's (LR) LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels.
The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? Central venous pressure of 6 mm Hg Mean arterial pressure of 70 mm Hg Urine output of 0.2 mL/kg/hr ScvO2 of 60%
Mean arterial pressure (MAP) of 70 mm Hg The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.
Which positioning strategy should be used for a client diagnosed with hypovolemic shock? Supine Modified Trendelenburg Prone Semi-Fowler
Modified Trendelenburg Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.
A client has sustained a long bone fracture and the nurse is preparing the client's care plan. Which of the following should the nurse include in the care plan? Administer vitamin D and calcium supplements as prescribed. Monitor temperature and pulses of the affected extremity. Perform passive range of motion exercises as tolerated. Administer corticosteroids as prescribed.
Monitor temperature and pulses of the affected extremity. The nurse should include monitoring for sufficient blood supply by assessing the color, temperature, and pulses of the affected extremity.
Which of the following is the analgesic of choice for burn pain? Morphine sulfate Fentanyl Demerol Tylenol with codeine
Morphine sulfate
Which term refers to the failure of fragments of a fractured bone to heal together? Dislocation Subluxation Nonunion Malunion
Nonunion When nonunion occurs, the client reports persistent discomfort and movement at the fracture site. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Malunion refers to growth of the fragments of a fractured bone in a faulty position, forming an imperfect union.
The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? Age Weight Preexisting conditions Family history
Preexisting conditions Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space.
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 fat emboli Related to infection Related to femoral artery occlusion Related to circumferential eschar
Related to circumferential eschar 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.
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory alkalosis pH 7.51 is high - alkalosis. PaCO2 28 is low - respiratory A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component.
The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? Septic Anaphylactic Neurogenic Cardiogenic
Septic Septic is an infection, so the temperature is raised to a fever. That's unique to septic shock.
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? Superficial Full-thickness Superficial partial-thickness Deep partial-thickness
Superficial
When a client is in the compensatory stage of shock, which symptom occurs? Bradycardia Urine output of 45 mL/hr Tachycardia Respiratory acidosis
Tachycardia Compensatory = respiratory alkalosis, tachycardia
The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following? The difference between an apical and radial pulse The difference between an upper extremity and lower extremity blood pressure The difference between the systolic and diastolic pressure The difference between the arterial and venous blood pressure
The difference between the systolic and diastolic pressure
A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? It helps determine the percentage of the total body surface area (TBSA) that is burned. The client's condition is likely to deteriorate after 72 hours. The wound is susceptible to infections. The early appearance of the burn injury may change.
The early appearance of the burn injury may change.
The nurse is caring for a client who has been diagnosed with chronic obstructive pulmonary disease (COPD) and is experiencing respiratory acidosis. The client asks what is making the acidotic state. What does the nurse identify as the result of the disease process that causes the fall in pH? The lungs are unable to breathe in sufficient oxygen. The lungs are unable to exchange oxygen and carbon dioxide. The lungs have ineffective cilia from years of smoking. The lungs are not able to regulate carbonic acid levels.
The lungs are not able to regulate carbonic acid levels. In COPD, the client is able to breathe in oxygen, and gas exchange can occur, but the lungs' ability to remove the carbon dioxide from the system is limited.
When the client who has experienced trauma to an extremity reports severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the client is likely demonstrating signs of: complex regional pain syndrome. avascular necrosis of bone. a reaction to an internal fixation device. heterotrophic ossification.
complex regional pain syndrome. Complex regional pain syndrome is frequently chronic and occurs most often in women. Avascular necrosis is manifested by pain and limited movement. Pain and decreased function are the prime indicators of reaction to an internal fixation device. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.
A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. What depth of burn injury does the client have? full thickness (third degree) superficial (first degree) superficial partial-thickness or deep partial-thickness (second degree) fourth degree
full thickness (third degree) Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless.
The nurse is concerned that a client is developing multiple organ dysfunction syndrome (MODS). Place the signs/symptoms in the classic sequence in which this syndrome develops. Use all options. 1 kidney dysfunction 2 fluid balance 3 liver dysfunction 4 hypermetabolism 5 bleeding disorder 6 lung dysfunction 7 cardiovascular instability 8 neurologic deterioration
lung dysfunction fluid balance hypermetabolism liver dysfunction kidney dysfunction bleeding disorder cardiovascular instability neurologic deterioration The classic pattern for the development of MODS begins with the lungs as the client experiences progressive dyspnea and respiratory failure. Increasing amounts of IV fluids and vasoactive agents are then needed to support blood pressure and cardiac output. Signs of a hypermetabolic state occur next, which is characterized by hyperglycemia, hyperlactic acidemia, and an increased blood urea nitrogen level. After 7 to 10 days, signs of liver dysfunction (elevated bilirubin and liver function tests) and kidney dysfunction (elevated creatinine and anuria) develop. As the lack of tissue perfusion continues, the hematologic system becomes dysfunctional, which increases the risk of bleeding. The cardiovascular system becomes unstable and unresponsive to vasoactive medications, and the neurologic system deteriorates to a state of unresponsiveness or coma.
A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse? "You would have to stay here much longer because it takes a cast longer to dry." "A splint is applied when more swelling is expected at the site of injury." "It is best if an orthopedic doctor applies the cast." "Not all fractures require a cast."
"A splint is applied when more swelling is expected at the site of injury." Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint.
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 18% 27% 36% 45%
27% The TBSA would be 27%. That is 18% of the body surface for the anterior trunk and 9% for the left arm.
The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition? 300 mL 400 mL 500 mL 600 mL
300 mL An indicator of renal hypoperfusion is a urinary output of less than 30 mL/hr. An output of 300 mL in 12 hours is less than 30 mL/hr, which is indicative of oliguria.
A client with hypervolemia asks the nurse by what mechanism the sodium-potassium pump will move the excess body fluid. What is the nurse's best answer? Passive osmosis Free flow Passive elimination Active transport
Active transport The sodium-potassium pump actively moves sodium against the concentration gradient out of the cell, and fluid follows. The mitochondria is the powerhouse of the cell.
Which action would be most important postoperatively for a client who has had a knee or hip replacement? Providing crutches to the client. Assisting in early ambulation. Using a continuous passive motion (CPM) machine. Encouraging expressions of anxiety.
Assisting in early ambulation. An anticoagulant therapy and early ambulation are important for clients who undergo a knee or hip replacement.
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? Obstructive Hypovolemic Carcinogenic Circulatory (distributive)
Circulatory (distributive) Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock.
Which would be contraindicated as a component of self-care activities for the client with a cast? Cover the cast with plastic to insulate it Cushioning rough edges of the cast with tape Elevate the casted extremity to heart level frequently Do not attempt to scratch the skin under a cast
Cover the cast with plastic to insulate it The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin.
The client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which complication? Dislocation of the hip Re-fracture of the hip Contracture of the hip Avascular necrosis of the hip
Dislocation of the hip
A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply. Hypovolemic shock; blood loss Obstructive shock; kidney stone Cardiogenic shock; myocardial infarction Anaphylactic shock; nut allergy Septic shock; infection Neurogenic shock; diabetes
Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nut allergy Septic shock; infection Obstructive shock occurs when there is interfere in blood flow through the heart . Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.
What is the major clinical use of dobutamine? increase cardiac output. prevent sinus bradycardia. treat hypotension. treat hypertension.
Increase cardiac output Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.
The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? Central venous pressure of 6 mm Hg Mean arterial pressure of 70 mm Hg Urine output of 0.2 mL/kg/hr ScvO2 of 60%
Mean arterial pressure of 70 mm Hg Targets: central venous pressure of 8 to 12 mm Hg mean arterial pressure >65 mm Hg urine output of 0.5 mL/kg/hr an ScvO2 of 70%.
A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: Oxygen at 2 L/min by nasal cannula Morphine 2 mg intravenously NS at 60 mL/hr via an intravenous line Dopamine (Intropin) intravenous solution
Oxygen at 2 L/min by nasal cannula In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.
A client experienced hemorrhage following a gunshot to the chest and received massive amounts of fluids. The client is now stable. The nurse assesses abdominal pressure as 12 mm Hg. The most immediate nursing intervention is to: Raise the head of the client's bed. Turn the client every 2 hours. Insert a rectal tube for decompression. Begin measurements of abdominal girth.
Raise the head of the client's bed. Normal abdominal pressures are 0 to 5 mm Hg. The client may be experiencing abdominal compartment syndrome, an increase in the pressure of the abdominal cavity. This is from fluid leaking into the intra-abdominal cavity and results in elevating the client's diaphragm. Raising the head of the bed will promote easier breathing. The other options may be done by the nurse, but ensuring adequate oxygenation is the priority.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum sodium level of 124 mEq/L Serum creatinine level of 0.4 mg/dl Hematocrit of 52% Serum blood urea nitrogen (BUN) level of 8.6 mg/dl
Serum sodium level of 124 mEq/L In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.
An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? The presence of leg shortening The client's complaints of pain Signs of neurovascular compromise The presence of internal or external rotation
Signs of neurovascular compromise Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.
The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient? The patient has developed a stress ulcer that is bleeding. The patient is having a reaction to the vasoconstricting medications. The patient has a tumor in the esophagus. The patient has bleeding esophageal varices.
The patient has developed a stress ulcer that is bleeding. GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus.
A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels? distributive cardiogenic hypovolemic organ failure
distributive Distributive shock results from displacement of blood volume, creating pooling of blood in the peripheral blood vessels. Cardiogenic shock results from the failure of a heart as a pump. With hypovolemic shock, there is a decrease in the intravascular volume. Organ failure is not a type of shock.
A fracture is considered pathologic when it: results in a fragment of bone being pulled away by a ligament or tendon and its attachment. occurs through an area of diseased bone. involves damage to the skin or mucous membranes. presents as one side of the bone being broken and the other side being bent.
occurs through an area of diseased bone. Pathologic as in resulting from an existing pathology rather than trauma
A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "Are the victims suffering from thermal burns?" "How many victims are anticipated for transport?" "Are the burns associated with chemicals used in the plant?" "Are any of the victims expected to have electrical burns?"
"Are the burns associated with chemicals used in the plant?" If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff.
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? 9% 18% 27% 36%
36% According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area.
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer? Blood products 5% albumin 6% dextran 6% hetastarch
5% albumin Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein, and it is too big to exit the capillaries, so it draws fluid into the blood vessels from the third space. The disadvantage of albumin is its high cost compared to crystalloid solutions. Hetastarch and dextran solutions are not indicated for fluid administration because these agents interfere with platelet aggregation. Blood products are not indicated in this situation.
The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. 60 mm Hg 70 mm Hg 80 mm Hg 90 mm Hg
60 mm Hg ICU goal is usually MAP > 65
A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first? Obtain the name and information of the allergic substance. Administer an epinephrine injection as ordered by the health care provider. Obtain a health history. Call 911.
Administer an epinephrine injection as ordered by the health care provider. The key words in the question are "increasing symptoms." The first action of the nurse is to administer an epinephrine injection to abort the rapidly increasing symptoms. Next, the nurse will call 911.
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next: Administers oxygen by nasal cannula at 2 liters per minute Re-assesses the vital signs Contacts the admitting physician Calls the Rapid Response Team
Administers oxygen by nasal cannula at 2 liters per minute The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? Hormone antagonist drugs Antimetabolite drugs Adrenergic drugs Anticholinergic drugs
Adrenergic drugs Adrenergic drugs are the main medications used to treat shock due to their action on the receptors of the sympathetic nervous system. Reference:
When is it advisable for the nurse to apply heat to a sprain or a contusion? Do not apply at all Immediately After 2 days Only after a week
After 2 days First two days need cooling to reduce possible swelling. After 2 days it's unlikely to swell more, now heat can relieve pain and improve circulation to the area
A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? Unstable angina pectoris Aortic insufficiency Hypertension Diabetes mellitus
Aortic insufficiency CP's explanation is trash. Aortic insufficiency = the aortic valve is dysfunctional, regurgitates blood back into LV. An intra-aortic pump can't do much if there's not a lot of blood in the aorta.
Which intervention should the nurse implement with the client who has undergone a hip replacement? Instruct the client to avoid internal rotation of the leg. Place the client in high Fowler's position for meals. Have the client bend forward to rise from the chair. Adduct the legs by placing a pillow between the legs.
Instruct the client to avoid internal rotation of the leg. The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. A pillow is used to keep the legs in abduction. The hip should not bend more than 90 degrees when seated. The head of bed should be kept at 60 degrees or less.
Morphine sulfate has which of the following effects on the body? Reduces preload Increases preload Increases afterload No effect on preload or afterload
Reduces preload In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).
A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations.
A client presents at the emergency department with a compound fracture of the right femur. Skeletal traction is applied to align the bones. What type of traction would be used? Steinmann traction Buck's traction Russell traction Thomas splint
Steinmann traction Skeletal traction is applied directly to a bone by using a wire (Kirschner), pin (Steinmann), or cranial tongs (Crutchfield). Bucks = weight at the foot for leg/hip fractures Russel = leg is pulled up and out to realign femoral fractures Thomas: splint lower leg to immobilize and align
An elite high school football player has been diagnosed with a shoulder dislocation. The client has been treated and is eager to resume his role on his team, stating that he is not experiencing pain. What should the nurse emphasize during health education? The need to take analgesia regardless of the short-term absence of pain The importance of adhering to the prescribed treatment and rehabilitation regimen The fact that he has a permanently increased risk of future shoulder dislocations The importance of monitoring for intracapsular bleeding once he resumes playing
The importance of adhering to the prescribed treatment and rehabilitation regimen Athletes are often highly motivated to return to their previous level of activity. Adherence to restriction of activities and gradual resumption of activities need to be reinforced. Appropriate analgesia use must be encouraged, but analgesia does not necessarily have to be taken in the absence of pain. If healing is complete, the client does not likely have a greatly increased risk of reinjury. Dislocations rarely cause bleeding after the healing process.
A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: The balloon deflates prior to systole. The right foot is cooler than the left foot. Vesicular breath sounds are audible in the lung periphery. Bilateral pedal pulses are 1+.
The right foot is cooler than the left foot. Sign of low circulation, the rest is normal
Which statement describes external fixation? The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. The surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. The bone is restored to its normal position by external manipulation. The bone is surgically exposed and realigned.
The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In internal fixation, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. In closed reduction, the bone is restored to its normal position by external manipulation. In open reduction, the bone is surgically exposed and realigned.
What is the major clinical use of dobutamine? increase cardiac output. prevent sinus bradycardia. treat hypotension. treat hypertension.
increase cardiac output. Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Epinephrine hydrochloride, another catecholamine agent, can treat sinus bradycardia. Many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, can treat acute hypotension. Don't use catecholamine agents to treat hypertension because they may raise blood pressure.
A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next? ondansetron meperidine magnesium hydroxide loperamide
ondansetron (Zofran) An antiemetic medication, such as ondansetron, is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).