ER SHOCK BURNS TEST
A patient is hemorrhaging from an open wound on his leg. The nurse implements care using the following steps. Place them in the order in which the nurse would perform them. Use all options.
1. Provide firm direct pressure 2. Apply a pressure dressing 3. Elevate the leg 4. Immobilize the leg When a patient is hemorrhaging from a leg wound, first the nurse would apply direct firm pressure to control the bleeding. Next, the nurse would apply a pressure dressing, and elevate the injured area to stop venous and capillary bleeding if possible. Then, the area is immobilized to control blood loss.
The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?
Multiple organ failure Explanation: In the irreversible stage of shock, significant cells and organs are damaged. The client's condition reaches a "point of no return" despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.
A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level?
11:00 p.m. Explanation: The duration of action of acetaminophen ranges from 3 to 5 hours. Its half-life ranges from 1 to 3 hours. At least 4 hours should pass between the last dose and laboratory assessment of the acetaminophen level.
A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?
18 Explanation: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this client.
The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury?
3422 Explanation: Convert pounds. to kilograms = 130/2.2 = 59 kg 2 mL x 59 kg x 58% TBSA = 6844 mL/24 hr. 6844/2 = 3422, so the nurse will administer 3422 mL over the first 8 hours and the remaining 3422 mL over the next 16 hours. The infusion is regulated so that one-half of the calculated volume is administered in the first 8 hours after burn injury. The second half of the calculated volume is administered over the next 16 hours. Fluid resuscitation formulas are only a guideline. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response.
Which client should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below?
A client with a blunt chest trauma with some difficulty breathing Explanation: The client with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation is prioritized over other health problems, including skeletal injuries and changes in cognition.
Which type of shock occurs from an antigen-antibody response?
Anaphylactic Explanation: During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.
A client is brought to the emergency department by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse determines which intervention should be completed first?
Apply a cervical collar on the client Explanation: Until it is known that the client has no fractures, it is imperative that a neck collar be applied and remain in place and that the client is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.
Which type of graft utilizes the client's own skin for wound coverage?
Autograft Explanation: An autograft uses the client's own skin, which is transplanted from one part of the body to another. A heterograft is obtained from animals, principally pigs. An allograft is human skin obtained from a cadaver. A slit graft is used when the area available as a donor site is limited, as in clients with extensive burns.
A client is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A. Determine whether the client has ingested a corrosive substance. B. Check the client's blood glucose level.
B. Check the client's blood glucose level. Hypoglycemia can mimic alcohol intoxication and should be assessed in a client suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication.
A client with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this client's care?
Ensuring IV access Explanation: ED nursing responsibilities include ensuring airway and IV access. Nurses are not normally responsible for notifying family members. Nurses collect specimens, but are not responsible for their delivery. Health care providers or other team members with specialized training intubate the client.
A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the client?
Ensuring continuous ECG monitoring Explanation: A hypothermic client requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not performed and bronchodilators would normally be insufficient to meet the client's respiratory needs.
A client presents to the emergency department after being stung by a bee, complaining of difficulty breathing. What vasoconstrictive medication should be given at this time?
Epinephrine Explanation: Anaphylactic shock is caused by a severe allergic reaction, such as to a bee sting, when patients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen- antibody reaction; specifically, an immunoglobulin E (IgE)- mediated response. Intramuscular epinephrine is administered for its vasoconstrictive action. Diphenhydramine (Benadryl) is administered IV to reverse the effects of histamine, thereby reducing capillary permeability. Dexamethasone and prednisone are corticosteroids, which treat inflammation; they do not have vasoconstrictive properties, however.
A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug?
Flumazenil Explanation: Lorazepam is a nonbarbiturate sedative whose effects are reversed with flumazenil. Naloxone is used to reverse the effects of opioids. Diazepam is used to treat seizures associated with drug overdose. It would not be used here, because it is in the same class as lorazepam and concurrent administration would add to the patient's overdose state. N-acetylcysteine is the antidote for acetaminiophen toxicity.
A child tips a pot of boiling water onto his bare legs. The mother should:
Immerse the child's legs in cool water. Explanation: The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage.
Which solid organ is most frequently injured in a penetrating trauma?
Liver Explanation: The most frequently injured solid organ in a penetrating trauma is the liver because of its size and anterior placement in the right upper quadrant of the abdomen
A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound?
Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream Explanation: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a type of silver dressing.
A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?
Massaging the feet Explanation: For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.
Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg?
Progressive Explanation: In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.
A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?
Rinsing the area with copious amounts of water Explanation: The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn.
A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find?
Spontaneous coughing If a patient can breathe and cough spontaneously, a partial airway obstruction should be suspected. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were a complete airway obstruction.
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?
Urine output of 20 ml/hour Explanation: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.
A patient in the emergency department is bleeding profusely from numerous large and deep lacerations on the top of his head, right side of his face, and forehead. The nurse determines the need to apply pressure at the appropriate pressure point. The nurse would use which of the following pressure points?
near ear The location of the injuries and site of bleeding determine which pressure point to use. In this case, the patient's bleeding is proximal to the temporal artery; therefore, pressure should be applied to this area, as shown in option A. If the patient was bleeding from the lower portion of the face, pressure would be applied to the facial artery, as in option B. The carotid artery would be used to control bleeding proximal to that area. The subclavian artery would be used to control bleeding proximal to it, such as the lower neck and shoulder area.
Which positioning strategy should be used for a client diagnosed with hypovolemic shock?
Modified Trendelenburg Explanation: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness
Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?
Myoglobin in the urine Explanation: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.
A nurse is providing wound care to a patient who arrived at the emergency department after being hit by flying glass from a broken window. The nurse asks the patient about his last tetanus shot. Which statement would indicate to the nurse that the patient needs a tetanus booster?
"It must be at least 6 or 7 years since I had one." Tetanus prophylaxis is administered as prescribed, based on the condition of the wound and the patient's immunization status. If the patient's last tetanus booster was administered more than 5 years ago, or if the patient's immunization status is unknown, he or she requires a tetanus booster. Thus, the patient's statement about it being at least 6 or 7 years would indicate to the nurse that the patient needs a booster immunization.
A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priorityin the care of a client who has been burned and suffered smoke inhalation?
Airway management Explanation: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.
A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action?
Brushing off all traces of the chemical from the patient's skin Explanation: For a chemical burn involving lye or white phosphorous, all evidence of the chemical should be brushed off the patient before any flushing occurs. These chemicals, if exposed to water, have the potential for exploding or for deepening the burn. Covering the burn area or applying ice is an inappropriate action.
A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client's health problem?
Cells lack an adequate blood supply and are deprived of oxygen and nutrients. Explanation: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock. Reference:
The nurse is providing care to a client who was brought to hospital with a opioid overdose. The nurse should expect to include which immediate interventions in the care of this client? Select all that apply. A. Monitor naloxone intravenous infusion B. Ensure the head of the bed remains elevated
A. Monitor naloxone intravenous infusion B. Ensure the head of the bed remains elevated Interventions in the urgent care of a client who has overdosed on an opioid narcotic focuses on reversal of the effects of the narcotic agent and supporting oxygenation. The nurse should ensure the client has the head of the bed elevated to aid respirations and monitor the intravenous infusion of naloxone, an opioid narcotic reversal agent. Applying a warming blanket to a client in this state should not be considered an immediate intervention as the blanket may interfere with the nurse's ability watch respirations closely. This may also risk causing the client hyperthermia. The CIWA-A scale would be appropriate in assessing withdrawal from alcohol. Respirations need to be assessed more closely than every 4 to 6 hours when immediate, more urgent care is being provided to prevent respiratory depression.
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?
Hypovolemia Explanation: Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.
Which of the following types of shock will a nurse observe in a client with extensive burns?
Hypovolemic shock Explanation: Clients with extensive burns may exhibit hypovolemic shock due to the loss of blood or plasma. Clients with extensive burns are unlikely to display the symptoms of anaphylactic, neurogenic, or septic shock.
A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the client's frostbite?
Immerse affected extremities in water slightly above normal body temperature. Explanation: Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
A client suffering from carbon monoxide poisoning would exhibit which manifestation?
Intoxication Explanation: A client suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the client with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign.
The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?
Intravenous Explanation: Intravenous administration is necessary because of altered tissue perfusion from burn injury.
Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis?
Irreversible Explanation: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage. ]
The nurse is caring for a client admitted with cardiogenic shock. The client is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this client?
It dilates the blood vessels. Explanation: For clients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the client's anxiety. Morphine would not be prescribed to promote coping or to stimulate the client. The rationale behind using morphine would not be to decrease gastric secretions.
A nurse suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply. Lack of sweating Temperature 105 degrees F (40.6 degrees C) Delirium
Lack of sweating Temperature 105 degrees F (40.6 degrees C) Delirium A patient with heat stroke typically exhibits a temperature of 105 degrees F (40.6 degrees C) or higher; profound central nervous system dysfunction; hot, dry skin; anhidrosis (absence of sweating); tachypnea; hypotension; and tachycardia. Increased thirst and weakness would suggest heat exhaustion.
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?
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.
A nurse in the ICU receives report from the nurse in the ED about a new client being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that client is probably experiencing?
Neurogenic shock Explanation: Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.
Which drug is a vasodilator used in the treatment of shock?
Nitroglycerin Explanation: Nitroglycerin is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Dopamine and dobutamine are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Norephinephrine is a vasoconstrictor used to increase blood pressure by vasoconstriction.
The nurse anticipates that an immunosuppressed client is at greatest risk for which type of shock?
Septic Explanation: Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. Neurogenic shock is associated with spinal cord injury and anesthesia. Cardiogenic shock is associated with heart disease. Anaphylactic shock is associated with hypersensitivity reactions.
You are assessing a 6-year-old girl in the Emergency Department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child?
She is having an allergic reaction and going into anaphylactic shock. Explanation: Anaphylactic shock is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive. Common allergic substances include bee venom, latex, fish, nuts, and penicillin. The body's immune response to the allergic substance causes mast cells in the connective tissues, bronchi, and gastrointestinal tract to release histamine and other chemicals. The results are vasodilatation, increased capillary permeability accompanied by swelling of the airway and subcutaneous tissues, hypotension, and hives or an itchy rash. Cardiogenic shock, neurogenic shock, and obstructive shock would not begin with vasodilation, swelling of the airway and hives. Therefore, options A, C ,and D are incorrect.
Which type of burn is similar to a sunburn?
Superficial partial-thickness Explanation: A superficial partial-thickness burn is similar to a sunburn. Deep partial thickness burns may need debridement and may scar. Full-thickness burns destroy all layers of the skin and consequently are painless. Electrical burns are a type of burn but not a category of burn thickness.
When a client is in the compensatory stage of shock, which symptom occurs?
Tachycardia Explanation: The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.
The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following?
The difference between the systolic and diastolic pressure Explanation: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.
What is a common source of airway obstruction in an unconscious client?
The tongue Explanation: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.
A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure?
hemoconcentration Explanation: The client with a burn experiences hemoconcentration when the plasma component of blood is lost or trapped. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure.
An 85-year-old client is admitted to the ED. Heat stroke is suspected. The client's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the client will include
immersion of the client in a cold-water bath. Explanation: For the client with heat stroke, simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing; formerly called the ABCs) of basic life support. This includes establishing IV access for fluid administration. After the client's clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour. One or more of the following methods may be used as prescribed: cool sheets and towels or continuous sponging with cool water; ice applied to the neck, groin, chest, and axillae while spraying with tepid water; and cooling blankets. Immersion of the client in a cold-water bath is the optimal method for cooling (if available). Hydration would be with lactated Ringer solution. There is no indication for intubation. Administration of sodium supplements is indicated for the treatment of heat cramps.
Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in the
lungs. Explanation: During MODS, the organ failure usually begins in the lungs and is followed by failure of the liver, gastrointestinal system, and kidneys.
