exam 3 practice questions
The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?
27%
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours?
600 mL
. A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.
A
1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? a.Frequent neurological assessments b.Side to side position changes c.Range of motion to extremities d.Frequent oropharyngeal suctioning
A
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's solution. d. Administer the ordered hydromorphone (Dilaudid).
A
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution.
A
Acute kidney injury from postrenal etiology is caused by a. obstruction of the flow of urine. b. conditions that interfere with renal perfusion. c. hypovolemia or decreased cardiac output. d. conditions that act directly on functioning kidney tissue.
A
An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a) Level I b) Level II c) Level III d) Level IV
A
An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings.
A
Continuous venovenous hemofiltration is used for what purpose? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Remove fluids and solutes through the process of convection. b Combine ultrafiltration, convection and dialysis. c Remove plasma water in cases of volume overload. d Remove plasma water and solutes by adding dialysate.
A
Renin plays a role in blood pressure regulation by a. activating the renin-angiotensin-aldosterone cascade. b. suppressing angiotensin production. c. decreasing sodium reabsorption. d. inhibiting aldosterone release.
A
The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.
A
The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should a. assess that the blood tubing is warm to the touch. b. assess the hemofilter every 6 hours for clotting. c. cover the dialysis lines to protect them from light. d. use clean technique during vascular access dressing changes.
A
The most common cause of acute kidney injury in critically ill patients is a. sepsis. b. fluid overload. c. medications. d. hemodynamic instability.
A
The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a. Monitor the patient's airway patency. b. Elevate the head of the patient's bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding.
A
The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a. Monitor the patient's airway patency. b. Elevate the head of the patient's bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding.
A
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.
A
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient's urine output has been less than 20 mL/hour for the past 2 hours. The patient's blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should a. contact the provider and expect a prescription for a normal saline bolus. b. wait until the provider makes rounds to report the assessment findings. c. continue to evaluate urine output for 2 more hours. d. ignore the urine output, as this is most likely postrenal in origin.
A
The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a) Placement of an IO catheter b) Placement of a central line c) Insertion of a femoral catheter by a trauma surgeon d) Rapid transfer to the OR
A
The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patient's mouth and insert a padded tongue blade. d. Restrain the patient's extremities until the seizure subsides.
A
The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for insertion of a. a percutaneous catheter at the bedside. b. a percutaneous tunneled catheter at the bedside. c. an arteriovenous fistula. d. an arteriovenous graft.
A
When paramedics report singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Inhalation injury above the glottis may cause significant edema that obstructs the airway. b The patient will have a copious amount of mucus that will need to be suctioned. c Carbon monoxide poisoning always occurs when soot is visible. d The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.
A
Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns
A
Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
A
A 100-kg patient gets hemodialysis 3 days a week. In planning the care for this patient, the nurse recommends a. a diet of 2500 to 3500 kcal per day. b. protein intake of less than 50 grams per day. c. potassium intake of 10 mEq per day. d. fluid intake of less than 500 mL per day.
A Nutritional recommendations include the following: caloric intake of 25 to 35 kcal/kg of ideal body weight per day (2500 to 3500 kcal) and protein intake of no less than 0.8 g/kg body weight. Patients who are extremely catabolic such as those on hemodialysis should receive protein in the amount of 1.5 to 2 g/kg of ideal body weight per day, 75% to 80% of which contains all the required essential amino acids; sodium intake of 0.5 to 1.0 g/day; potassium intake of 20 to 50 mEq/day; calcium intake of 800 to 1200 mg/day; fluid intake equal to the volume of the patient's urine output plus an additional 600 to 1000 mL/da
The patient's potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction? a. Sodium polystyrene sulfonate b. Sodium polystyrene sulfonate with sorbitol c. Regular insulin d. Calcium gluconate
A Only dialysis and administration of cation exchange resins (sodium polystyrene sulfonate) actually reduce plasma potassium levels and total body potassium content in a patient with renal dysfunction. In the past, sorbitol has been combined with sodium polystyrene sulfonate powder for administration. The concomitant use of sorbitol with sodium polystyrene sulfonate has been implicated in cases of colonic intestinal necrosis; therefore, this combination is not recommended. Other treatments, such as administration of regular insulin and calcium gluconate, "protect" the patient for only a short time until dialysis or cation exchange resins can be instituted.
The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient's temperature is elevated. The nurse should a. assess peritoneal dialysate return. b. check the patient's blood sugar. c. evaluate the patient's neurological status. d. inform the provider of probable visceral perforation.
A Peritonitis is the most common complication of peritoneal dialysis therapy and is usually caused by contamination in the system. Peritonitis is manifested by abdominal pain, cloudy peritoneal fluid, fever and chills, nausea and vomiting, and difficulty in draining fluid from the peritoneal cavity.
The nurse is caring for a renal transplant recipient in the post-anesthesia care unit. Blood pressure is 125/70 mm Hg; heart rate is 115 beats/min; respiratory rate is 24 breaths/min; oxygen saturation (SpO2) is 95% on 3 L/min of oxygen via nasal cannula, temperature is 97.8° F, and the central venous pressure (CVP/RAP) is 2 mm Hg. What is the best action by the nurse? a. Administer fluid replacement therapy; monitor intake and output closely. b. Increase supplemental oxygen to 100% non-rebreather mask; notify physician. c. Apply thermal warming blanket; administer all fluids through warming device. d. Assess the patient for pain; administer pain medications as ordered.
A because CVP is 2 needs fluid therapy
Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg
A risk for ineffective breathing
The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician order should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous
A- priority to decrease ICP
Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.) a. Hypotension b. Dysrhythmias c. Muscle cramps d. Hemolysis e. Air embolism
AB
The trauma nurse understands which information related to the older trauma patient? (Select all that apply.) a) Falls are the leading cause of death in the older population. b) Physiologic capacity is an important predictor of outcome. c) Hypotension in the elderly can appear as normotension. d) Chronic diseases don't have much effect on the older trauma patient. e) Fractures to bones other than hips are uncommon from trauma.
ABC
Which of the following statements apply to trauma patients and their potential complications? (Select all that apply.) a) Indwelling urinary catheters are a source of infection. b) Patients often develop infection and sepsis secondary to central line catheters. c) Pneumonia is often an adverse outcome of mechanical ventilation. d) Wounds require sterile dressings to prevent infection.
ABC
Noninvasive diagnostic procedures used to determine kidney function include which of the following? (Select all that apply.) a. Kidney, ureter, bladder (KUB) x-ray b. Renal ultrasound c. Magnetic resonance imaging (MRI) d. Intravenous pyelography (IVP) e. Renal angiography
ABC only options that are noninvasive
Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a) Prevention of hypothermia b) Administration of fresh frozen plasma as ordered c) Administration of potassium as ordered d) Administration of calcium as ordered e) Monitoring CBC and coagulation studies
ABD
During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Chest wall ecchymosis b Signs of hypoxia on room air c Diminished or absent breath sounds d Pink-tinged or blood secretions e Fractured ribs
ABDE
It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Coagulopathies b Reduced tissue perfusion c Acute respiratory distress syndrome (ARDS) d Dysrhythmias e Myocardial dysfunction
ABDE
Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event? (Select all that apply.) a) Establish a family spokesperson and communication system. b) Ask the family about their normal coping mechanisms. c) Limit visitation to set times throughout the day. d) Coordinate a family conference. e) Determine how the family perceives the event.
ABDE
In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) Multiple answers: Multiple answers are accepted for this question Select one or more answers and submit. For keyboard navigation...SHOW MORE a Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. b Presence of cervical injuries is a contraindication to the assessment of this reflex. c Eye movement in the same direction as the head when turned indicates an intact reflex. d Eye movement in the opposite direction as the head when turned indicates an intact reflex. e Doll's eyes present indicate brainstem activity. f Doll's eyes absent indicate a disruption in normal brainstem processing.
ABDEF
An autograft is used to optimally treat a partial- or full-thickness wound that meets what criteria? (Select all that apply.) Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Involves a joint. b Involves the face, hands, or feet. c Is infected. d Involves very large surface areas e Requires more than 2 weeks for healing.
ABE
The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury.
AC
Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a) Crush injury to right arm b) Gunshot wound to the abdomen c) Lightening strike of the left arm and chest d) Pulmonary contusion and rib fracture e) Penetrating wound to both legs
AC Causes of rhabdomyolysis include crush injuries, compartment syndrome, burns, and injuries from being struck by lightning.
The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.) a. bladder catheterization. b. increasing fluid volume intake. c. ureteral stenting. d. placement of nephrostomy tubes. e. increasing cardiac output.
ACD
The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.) a. evaluate morning laboratory results and report abnormal results. b. administer the patient's antihypertensive medications. c. assess the dialysis access site and report abnormalities. d. weigh the patient to monitor fluid status. e. give all medications except for antihypertensive medications.
ACD
Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Crush injury to right arm b Gunshot wound to the abdomen c Second degree burns to 40% of the body d Lightning strike of the left arm and chest e Pulmonary contusion and rib fracture
ACD
During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a) Chest wall ecchymosis b) Diminished or absent breath sounds c) Pink-tinged or blood secretions d) Signs of hypoxia on room air e) Paradoxical chest wall movement
ACD Pulmonary contusion is a serious injury associated with deceleration or blast forces and is a common cause of death after chest trauma. The clinical presentation includes chest wall abrasions, ecchymosis, bloody secretions, and a partial pressure of arterial oxygen (PaO2) of less than 60 mm Hg while breathing room air. The bruised lung tissue becomes edematous, resulting in hypoxia and respiratory distress.
The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.) a. Acidosis b. Hypokalemia c. Volume overload d. Hyperkalemia e. Uremia
ACDE
Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.) a) MAP 48 mmHg b) Elevated serum blood alcohol level c) Nonreactive pupils d) RR of 10 breaths/min e) Open skull fracture
ACDE
Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Delayed fluid resuscitation b Electrical burn injury c Burn injury less than 10% d Bedrest e Burns to lower extremities
ADE
A normal glomerular filtration rate is a. less than 80 mL/min. b. 80 to 125 mL/min. c. 125 to 180 mL/min. d. more than 189 mL/min.
B
During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent a) DIC b) multisystem organ dysfunction c) septic shock d) wound infection
B
Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis a. is more frequently used for acute kidney injury. b. uses the patient's own semipermeable membrane (peritoneal membrane). c. is not useful in cases of drug overdose or electrolyte imbalance. d. is not indicated in cases of water intoxication.
B
Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent a) catheter-associated infection b) VTE c) fat embolism d) nosocomial pneumonia
B
The critical care nurse knows that in critically ill patients, renal dysfunction a. is a very rare problem. b. affects nearly two thirds of patients. c. has a low mortality rate once renal replacement therapy has been initiated. d. has little effect on morbidity, mortality, or quality of life.
B
The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.
B
The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order by the physician should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam (Ativan). c. Obtain stat portable chest x-ray. d. Administer phenytoin (Dilantin).
B
The nurse is caring for a postoperative renal transplant recipient in the critical care unit. After seeing minimal urine output in the catheter for most of the day, the patient expresses concern to the nurse. What is the best response by the nurse? a. "Your kidney has unfortunately failed and will be removed." b. "It can take a few days for your kidney to start working" c. "You are experiencing an acute rejection episode." d. "You will have to undergo daily hemodialysis treatments."
B
The nurse is caring for a renal transplant patient admitted with an acute rejection episode. The patient asks the nurse how the doctors will know if the kidney has been rejected. What is the best response by the nurse? a. "Your admission lab results will determine if your kidney is being rejected." b. "A procedure called a renal biopsy will be the best way to confirm rejection." c. "Monitoring over the next few days will determine if your kidney is failing." d. "An ultrasound of your kidney will determine if your kidney has failed."
B
The nurse is providing discharge instructions to a renal transplant recipient. The patient has a follow-up appointment the next day for routine post-transplant laboratory bloodwork, including trough levels of anti-rejection medications.Which instruction describes what the patient should do regarding the anti-rejection medications the next day? a. "Take your morning dose of medications at midnight with sips of water." b. "Take your morning dose of medications after labs have been drawn." c. "Skip your morning dose of medications and then resume your evening doses." d. "Hold all doses of your medications the day you have labs drawn."
B
The patient asks the nurse if the placement of the autograft over a full-thickness burn will be the only surgical intervention needed to close the wound. What is the nurse's best response? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a"An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." b"Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." Your answer c "Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound." d "Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound."
B
The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should a. prepare to assist with a routine dialysis catheter change. b. evaluate the patient for signs and symptoms of infection. c. teach the patient that the catheter is designed for long-term use. d. use one of the three lumens for fluid administration.
B
The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate a. increased nitrogen intake. b. acute kidney injury, such as acute tubular necrosis (ATN). c. hypovolemia. d. fluid resuscitation.
B
The patient's serum creatinine level is 0.7 mg/dL. The expected BUN level should be a. 1 to 2 mg/dL. b. 7 to 14 mg/dL. c. 10 to 20 mg/dL. d. 20 to 30 mg/dL.
B
The term used to describe an increase in blood urea nitrogen (BUN) and serum creatinine is a. oliguria. b. azotemia. c. acute kidney injury. d. prerenal disease.
B
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction
B
When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident? a) High-speed motor vehicle crashes b) Poisonings from prescription or illegal drugs c) Violent or domestic traumatic altercations d) Work-related falls
B
Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.
B
Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a) A fall from a 6-foot ladder onto the grass b) A shotgun wound to the abdomen c) A knife wound to the right chest d) An MVC in which the driver hits the steering wheel
B
The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. Blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; the patient has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for "stat" administration of a. a blood transfusion. b. fluid replacement with 0.45% saline. c. infusion of an inotropic agent. d. an antiemetic.
B This scenario indicates hypovolemia from the nausea and vomiting, requiring volume replacement. Hypovolemia resulting from large urine or gastrointestinal losses often requires the administration of a hypotonic solution, such as 0.45% saline.
What is a minimally acceptable urine output for a patient weighing 75 kg? a. Less than 30 mL/hour b. 37 mL/hour c. 80 mL/hour d. 150 mL/hour
B 0.5-1 ml/kg/hr
The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient's condition is a. prerenal. b. postrenal. c. intrarenal. d. not renal related.
B Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among thevarious causes of acute kidney injury. Postrenal conditions may present with stones,crystals, sediment, bacteria, and clots from the obstruction. Coarse, muddy brown granularcasts are classic findings in ATN (intrarenal), along with microscopic hematuria and a smallamount of protein. In prerenal conditions, the urine typically has no cells but may containhyaline casts. The flank pain and urinalysis definitely indicate a renal condition.
A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? a) Blood pressure 82/60 mm Hg, heart rate 122 beats/min, respiratory rate 28 breaths/min b) Crackles (rales) on auscultation of bilateral lung fields c) Responsive only to painful stimuli d) Irregular HR and rhythm
B Explosive blast energy generates shock waves that create changes in air pressure, causing tissue damage. Initially after an explosion, there is a rapid increase in positive pressure for a short period, followed by a longer period of negative pressure. The increase in positive pressure injures gas-containing organs. The tympanic membrane ruptures, and the lungs may show evidence of contusion, acute edema, or ruptur
The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing.
B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.
The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best qualifies for evaluation? a. A 65-year-old brother with a history of hypertension; blood type A positive b. A 35-year-old female with a history of food allergies; blood type O negative c. A 14-year-old son, otherwise healthy with no history; blood type B negative d. A 70-year-old mother, with a history of sinus infections; blood type A positive
B To qualify as a living donor, an individual must be free from hypertension, diabetes, cancer, kidney disease, and heart disease and generally between 18 and 60 years of age. A 35-year-old female with a history of food allergies; blood type O negative (universal donor) best qualifies for evaluation. The brother and mother, although blood-type compatible, are outside of acceptable age ranges for living donation. The minor son does not qualify based on blood type
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the physician of the patient's blood pressure.
B eliminate cause of suspected autonomic dysreflexia
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.
B indicates airway edema
The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene) infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? a. Stop the infusion for 5 minutes. b. Increase the dose by 2.5 mg/hr. c. Notify the physician of the BP. d. Begin weaning the infusion.
B not therapeutic level wants to be more decreased than that to prevent aneurysm
The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. What action by the nurse is best? a. Assess the patient's hearing. b. Assess the patient's lungs. c. Decrease IV fluids once the diuretic has been administered. d. Give extra doses before giving radiological contrast agents.
B risk for pulmonary edema
Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? (Select all that apply) a) 5% Dextrose is recommended for rapid crystalloid infusion. b) IV fluids may need to be warmed to prevent hypothermia. c) Massive transfusions should be avoided to improve patient outcomes. d) Only fully crossmatched blood products are administered. e) Hypertonic saline solutions are often used during initial resuscitation.
BC
It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a) ARDS b) Coagulopathies c) Dysrhythmias d) Myocardial dysfunction e) Fat embolism
BCD Prolonged hypothermia is associated with the development of myocardial dysfunction, coagulopathies, reduced perfusion, and dysrhythmias (bradycardia and atrial or ventricular fibrillation).
A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED a) includes a cervical spine x-ray study to determine the presence of a fracture. b) involves turning the patient from side to side to get a look at his back. c) is done quickly in the first few minutes to get a baseline assessment and establish priorities. d) is a methodical head-to-toe assessment identifying injuries and treatment priorities.
C
A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible non-burn injured skin disorder? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Graft versus host disease b Staphylococcal scalded skin syndrome c Toxic epidermal necrolysis d Necrotizing soft tissue infection
C
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 350 mL/hour b. 523 mL/hour c. 938 mL/hour d. 1250 mL/hour
C
Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as intrarenal. The most common intrarenal condition is a. prolonged ischemia. b. exposure to nephrotoxic substances. c. acute tubular necrosis (ATN). d. hypotension for several hours.
C
In the trauma patient, symptoms of decreased cardiac output are most commonly caused by a) cardiac contusion b) cardiogenic shock c) hypovolemia d) percardial tamponade
C
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)
C
The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.
C
The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should a. apply a sterile gauze dressing to maintain sterility. b. replace the transparent dressing every 10 days to prevent manipulation. c. assess the catheter site for redness and/or swelling. d. use the catheter for drawing blood samples to reduce patient discomfort.
C
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL
C
The patient has just returned from having an arteriovenous fistula placed. The patient asks, "When will they be able to use this and take this other catheter out?" The nurse should reply, a. "It can be used immediately, so the catheter can come out anytime." b. "It will take 2 to 4 weeks to heal before it can be used." c. "The fistula will be usable in about 4 to 6 weeks." d. "The fistula was made using graft material, so it depends on the manufacturer."
C
The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The patient complains of general malaise and is tachypneic. An arterial blood gas shows that the patient's pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to a. administer morphine to slow the respiratory rate. b. prepare for intubation and mechanical ventilation. c. administer intravenous sodium bicarbonate. d. cancel tomorrow's dialysis session.
C
The patient is on intake and output (I&O), as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should a. draw a trough level after the next dose of antibiotic. b. obtain an order to place the patient on fluid restriction. c. assess the patient's lungs. d. insert an indwelling catheter.
C
Which of the following best defines the term traumatic injury? a) All trauma patients can be successfully rehabilitated. b) Traumatic injuries cause more deaths than heart disease and cancer. c) Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d) Trauma mainly affects the older adult population.
C
Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a) A patient who has a closed head injury with a decreased level of consciousness b) A patient who has a fractured femur and is currently in traction c) A patient who has received large volumes of fluid and/or blood replacement d) A patient who has underlying COPD
C
The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of a. dialyzer membrane incompatibility. b. a shift in potassium levels. c. dialysis disequilibrium syndrome. d. hypothermia.
C Dialysis disequilibrium syndrome often occurs after the first or second dialysis treatment or in patients who have had sudden, large decreases in BUN and creatinine levels as a result of the hemodialysis. Because of the blood-brain barrier, dialysis does not deplete the concentrations of BUN, creatinine, and other uremic toxins in the brain as rapidly as it does those substances in the extracellular fluid. An osmotic concentration gradient established in the brain allows fluid to enter until the concentration levels equal those of the extracellular fluid. The extra fluid in the brain tissue creates a state of cerebral edema for the patient, which results in severe headaches, nausea and vomiting, twitching, mental confusion, and occasionally seizures. Dialyzer membrane incompatibility may cause hypotension. Hyperthermia, not hypothermia, may result if the temperature control devices on the dialysis machine malfunction. Potassium shifts may occur but would be manifested in cardiac dysrhythmias.
The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient's urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has: a. acute kidney injury from a prerenal condition. b. acute kidney injury from postrenal obstruction. c. intrarenal disease, probably acute tubular necrosis. d. a urinary tract infection.
C (course muddy brown casts indicative of ATN)
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.
C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor.
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light
C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.
The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which physician order should the nurse institute first? a. Blood cultures (2 specimens) for temperature > 101° F b. Acetaminophen (Tylenol) 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours
C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion.
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a. Both pressures are high. b. Both pressures are low. c. ICP is high; CPP is normal. d. ICP is high; CPP is low.
C ICP normal 0-15 CPP normal 60-100
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? a. 54 mm Hg b. 72 mm Hg c.90 mm Hg d.26 mm Hg
C MAP= CPP-ICP
The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg
C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both.
Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a) 30 mL/hr b) 50 mL/hr c) 100 mL/hr d) 300 mL/hr
C aggressive fluid resusication flushes the myoglobin from the renal tubules want to achieve UO of 100-200 mL/hr
Which of the following patients is at the greatest risk of developing acute kidney injury? a. a patient who has been on aminoglycosides for the past 6 days b. has a history of controlled hypertension with a blood pressure of 138/88 mm Hg c. was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks d. has a history of fluid overload as a result of heart failure
C aminoglycosides are nephrotoxic and this pt has longer term use of this drug therapy
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel
C high protein high cal
The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should a. reassess the patient in an hour. b. raise the arm above the level of the patient's heart. c. notify the provider immediately. d. apply warm packs to the fistula site and reassess.
C if no bruit, thrill or pulse there may not be perfusion past the fistula
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.
C with a suspected CSF leak drainage should be free flowing
The nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse include in this transfusion protocol? (Select all that apply.) a) Whole blood b) Universal donor blood only c) RBCs d) Platelets e) Plasma
CDE
Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also due to the patients' long-term management. Which of the following statements apply to trauma patients? (Select all that apply.) A. Wounds require sterile dressings to prevent infection. b Early ambulation is critical to achieving desired outcomes. c Indwelling urinary catheters are a source of infection. d Pneumonia is often an adverse outcome of mechanical ventilation. e Patients often develop infection and sepsis secondary to central line catheters.
CDE
The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device "prn" c. Recording ICP as a "mean" value d. Use of a pressurized flush system e. Zero referencing the transducer system
CE
A normal urine output is considered to be a. 80 to 125 mL/min. b. 180 L/day. c. 80 mL/min. d. 1 to 2 L/day.
D
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.
D
A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "I bet my boyfriend won't even want to look at me anymore." d. "Do you think dark beige makeup foundation would cover this scar on my cheek?"
D
After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F
D
Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that a. a hemofilter is used to facilitate ultrafiltration. b. it provides faster removal of solute and water. c. it does not allow diffusion to occur. d. the process removes solutes and water slowly.
D
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.
D
Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a) Absence of pulse in affected extremity b) Pallor in the affected area c) Paresthesia in the affected area d) Severe, throbbing pain in the affected area
D
The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a) Arterial oxygen saturation b) Hourly urine output c) Mean arterial pressure d) Serum lactate levels
D
The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. Assess for the presence of a headache. b. Assess the patient's general orientation. c. Determine the patient's drug allergies. d. Determine the time of symptom onset.
D
The nurse caring for a patient with an electrical injury understands that patients with electrical injury are at a high risk for acute kidney injury secondary to what related process? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Hypervolemia from burn resuscitation b Increased incidence of ureteral stones c Nephrotoxic antibiotics for prevention of infection d Release of myoglobin from injured tissues
D
The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.
D
The nurse is caring for a patient with acute kidney injury who is being treated with hemodialysis. The patient asks if he will need dialysis for the rest of his life. Which of the following would be the best response? a. "Unfortunately, kidney injury is not reversible; it is permanent." b. "Kidney function usually returns within 2 weeks." c. "You will know for sure if you start urinating a lot all at once." d. "Recovery is possible, but it may take several months."
D
The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)
D
The patient is in a progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should a. draw blood from the left arm. b. take blood pressures from the left arm. c. start a new intravenous line in the left lower arm. d. auscultate the left arm for a bruit and palpate for a thrill.
D
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.
D
Which clinical scenario best represents hyperacute rejection? a. A cardiac transplant patient with a 3-month history of shortness of breath b. A lung transplant patient with small pustules that follow a dermatome c. A liver transplant patient with several small lumps under the skin d. An implanted renal transplant that, upon reperfusion, becomes cyanotic
D
Which of the following interventions is a strategy to prevent fat embolism syndrome? a) Administer lipid-lowering stain medications b) Intubate the patient early after the injury to provide mechanical ventilation c) Provide prophylaxis w/ low-molecular weight heparin d) Stabilize extremity fractures early
D
An advantage of peritoneal dialysis is that a. peritoneal dialysis is time intensive. b. a decreased risk of peritonitis exists. c. biochemical disturbances are corrected rapidly. d. the danger of hemorrhage is minimal.
D Advantages of peritoneal dialysis include that the equipment is assembled easily and rapidly, the cost is relatively inexpensive, the danger of acute electrolyte imbalances or hemorrhage is minimal, and dialysate solutions can be individualized. In addition, automated peritoneal dialysis systems are available. Disadvantages of peritoneal dialysis include that it is time intensive, requiring at least 36 hours for a therapeutic effect to be achieved; biochemical disturbances are corrected slowly; access to the peritoneal cavity is sometimes difficult; and the risk of peritonitis is high.
The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient's urinalysis results. The nurse should become concerned when a. creatinine levels in the urine are similar to blood levels of creatinine. b. sodium and chloride are found in the urine. c. urine uric acid levels have the same values as serum levels. d. red blood cells and albumin are found in the urine.
D (indicates glomerular damage)
The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg
D CVP of 2 indicates potential hypovolemia; we want to ensure adequate cerebral perfusion
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the physician immediately.
D These are classic symptoms of epidural and acute subdural hematomas: injury, lucid period, and progressive deterioration. The physician must be notified of this neurological emergency so appropriate interventions can be implemented.
The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the provider and anticipates a) administration of lactated Ringer's solution (1 L) wide open. b) chest x-ray study to determine the etiology of the symptoms. c) ET intubation and mechanical ventilation. d) needle thoracotomy and chest tube insertion.
D classic s/s of tension pneumothorax
While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102° F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics.
D cooling measures are indicated to decrease fever and prevent increased ICP
The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patient's head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d.Provide rest periods between nursing interventions.
D do not want to sustain elevated ICP for >5 mins when the pt already has increased ICP. spacing will allow this not to happen
Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.
D higher IV fluid rate is needed
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.
D indicative of CO poisoning
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood
D prevents gi stress ulcers
A patient has been admitted to the emergency department with a massive hemothorax. What action by the nurse takes priority? a) Place the patient on a cardiac monitor b) Prepare for rapid intubation c) Seal the wound w/ occlusive dressings d) Start 2 large bore IVs
D will need blood transfusion
While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.
b
