FINALS 2 SET 3

2. The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

ACUTE **The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (ie, wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason? A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. B) Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient. C) A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary. D) There is great concern about electrolyte imbalances and the laboratory will monitor the urine for changes in potassium and sodium concentrations.

A Feedback: Hematuria is the most common manifestation of renal trauma; its presence after trauma suggests renal injury. Hematuria may not occur, or it may be detectable only on microscopic examination. All urine should be saved and sent to the laboratory for analysis to detect RBCs and to evaluate the course of bleeding. Measuring intake and output is not a function of the laboratory. The laboratory does not save urine to test creatinine clearance at a later time. The laboratory does not monitor the urine for sodium or potassium concentrations.

A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action? A) Inform the physician and assess the patient for signs of infection. B) Flush the peritoneal catheter with normal saline. C) Remove the catheter promptly and have the catheter tip cultured. D) Administer a bolus of IV normal saline as ordered.

A Feedback: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary care provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the physician would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection.

The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? A) Hematuria B) Precipitous decrease in serum creatinine levels C) Hypotension unresolved by fluid administration D) Glucosuria

A Feedback: The primary presenting feature of acute glomerulonephritis is hematuria (blood in the urine), which may be microscopic (identifiable through microscopic examination) or macroscopic or gross (visible to the eye). Proteinuria, primarily albumin, which is present, is due to increased permeability of the glomerular membrane. Blood urea nitrogen (BUN) and serum creatinine levels may rise as urine output drops. Some degree of edema and hypertension is noted in most patients.

Causes of Hypoxia

**Decreased FIO2** **Decreased Cardiac output**(decreased perfusion to lung) **Thickened membranes** such as conditions that cause pulmonary fibrosis, CF **Right to left shunt** also known as a ventilation to perfusion (V/Q) mismatch. Blood moves from the right side of the heart to the left without being oxygenated Anatomic- VSD Physiologic- ARDS, pneumonia, pulmonary edema, low HGB

Causes of Hypercapnic Respiratory Failure

**Hypoventilation** ( increased CO2 greater than 50 mmHg) COPD PE Pnuemothorax Respiratory depression Myasthenia gravis

A 1-kg weight gain is equal to

1,000 mL of retained fluid.

Initial Assessment: Primary Survey

A = Airway B = Breathing C = Circulation D = Disability E = Exposure F = Fracture

The nurse is planning teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula?

A vein and an artery in your arm will be attached surgically

3. A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis

A)

A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? A) Practice outside of her normal area of clinical expertise. B) Perform interventions that are not based on assessment data. C) Prioritize psychosocial needs over physiologic needs. D) Prioritize the interests of older adults over younger patients.

A)

A nurse takes a shift report and finds he is caring for a patient who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this patient? A) Standard precautions B) Airborne precautions C) Droplet precautions D) Contact precautions

A)

A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patient's diet to maximize the therapeutic effect and minimize the risks of complications. The patient's diet should include which of the following modifications? Select all that apply. A) Decreased Protein intake B) Decreased sodium intake C) Increased potassium intake D) Fluid restriction E) Vitamin D supplementation

A, B, D

The nurse receiving a patient from EMS who has been in a shooting and is brought to the emergency department with profuse bleeding from the abdomen. The patient has a NRB mask @ 15L and two large bore IV's are imitated Prioritize the nursing actions for this client. A-Assess vita signs B-Assess level of consciousness C-Infuse NS bolus as ordered D-Removed the patient's remaining clothing E-Obtain hgb/hct as ordered

A,C,B,D,E

- A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 beats per minute, respirations of 28 per minute, and Grey Turner's sign. What action should the nurse perform first? 1. Assess the urine output. 2. Place an intravenous line. 3. Position on the left side. 4. Insert a nasogastric tube.

2.

The nurse in the emergency department is triaging victims of an airpolalne crash. Prioritize the clients in the order in which they should be treated from first to last. 1- A 75 year old with a 2 inch laceration to the left forearm 2- A 22 year old with a 2 inch laceration to the chin, history of asthma, respirations 26 breaths/min, audible wheezing 3- A 14 year old with a 2 inch laceration to the chin, history of asthma, respirations 26 breaths/min, audible wheezing 4- A 22 year old female 36 weeks pregnant with contractions every 10 to 15 minutes

3,2,4,1

Most patients with ARDS develop diffuse alveolar infiltrates and progress to respiratory failure within

48 hours of the onset of symptoms.

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration

A

A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? Select all that apply. A) Perforation into the mediastinum B) Development of an esophageal lesion C) Erosion into the great vessels D) Painful swallowing E) Obstruction of the esophagus

A,C,E

Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is appropriate action for the nurse to take? A. Hold the feeding B. Reinstill the amount and continue with administering the feeding C. Elevate the client's head at least 45 degrees and administer the feeding D. Discard the residual amount and proceed with administering the feeding

A. Hold the feeding

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems? A) Diminished deep tendon reflexes B) Tachycardia C) Cool, clammy skin D) Acute flank pain

Ans: A Feedback: To gauge a patient's magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds

Ans: A Feedback: In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions.

Unlicensed Assistive Personnel (UAP) tell the nurse that the post-op patient has a blood pressure of 78/46 and a pulse of 113 using a vital signs machine. The nurse is currently administering medications. What intervention should the nurse implement first?

Assess the patient's cardiovascular status.

-A nurse is caring for patients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered? A) Level A B) Level B C) Level C D) Level D

B

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia

B Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord lesions above T6 after bspinal shock has resolved

A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? A) Assigning a high priority to the most critical injuries B) Doing the greatest good for the greatest number of people C) Allocating resources to the youngest and most critical D) Allocating resources on a first come, first served basis

B)

After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching? A) "It is important to use strict aseptic technique." B) "It is appropriate to warm the dialysate in a microwave." C) "The infusion clamp should be open during infusion." D) "The effluent should be allowed to drain by gravity."

B)

An industrial site has experienced a radiation leak and workers who have been potentially affected are en route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A) Place all potential victims on reverse isolation. B) Establish a triage outside the hospital. C) Have hospital staff put on personal protective equipment. D) Place hospital staff on abbreviated shifts of no more than 4 hours.

B)

-The nurse manager in the ED receives information that a local chemical plant has had a chemical leak. This disaster is assigned a status of level II. What does this classification indicate? A) First responders can manage the situation. B) Regional efforts and aid from surrounding communities can manage the situation. C) Statewide or federal assistance is required. D) The area must be evacuated immediately.

B) Regional efforts and aid from surrounding communities can manage the situation.

A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply. A) Coping B) Level of consciousness C) Oral intake D) Arterial blood gases E) Vital signs

B, D, E Patients are usually treated in the ICU. The nurse assesses the patients respiratory status by monitoringthe level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are notimmediate priorities during the acute stage of treatment, but would become more important later duringrecovery_

A nurse is caring for a patient who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this patient, the nurse should describe what aspect of this diagnostic procedure? A) The need to protect the incision postprocedure B) The use of moderate sedation C) The need to infuse 50% dextrose during the procedure D) The use of general anesthesia

B. The use of moderate sedation

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude? A) The system is functioning normally. B) The patient has a pneumothorax. C) The system has an air leak. D) The chest tube is obstructed.

C Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) Hypertensive emergency C) Spinal shock D) Hypovolemia

C In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function_

The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)? A) Hypernatremia B) Hypomagnesemia C) Hyperkalemia D) Hypercalcemia

C Feedback: Hyperkalemia, a common complication of acute kidney injury, is life-threatening if immediate action is not taken to reverse it. The administration of polystyrene sulfonate reduces serum potassium levels.

A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase? A) Hypokalemia B) Hypocalcemia C) Dehydration D) Acute flank pain

C Feedback: The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. The patient must be observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to increase. Excessive losses of potassium and calcium are not typical during this phase, and diuresis does not normally result in pain.

The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient? A) Using a stethoscope for auscultating the fistula is contraindicated. B) The patient feels best immediately after the dialysis treatment. C) Taking a BP reading on the affected arm can damage the fistula. D) The patient should not feel pain during initiation of dialysis.

C Feedback: When blood flow is reduced through the access for any reason (hypotension, application of BP cuff/tourniquet), the access site can clot. Auscultation of a bruit in the fistula is one way to determine patency. Typically, patients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, a needle stick is still painful.

Natural- devitalized tissue separates from underlying tissue spontaneously Mechanical- involves the use of surgical tools to separate and remove eschar until the point at which pain and bleeding occurs

Chemical- Topical enzymatic agents Surgical-Early surgical excision with early burn wound closure.

A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What actions should the intensive care nurse including during the phase of patient's care?

Communicate clearly and frequently with the patient's family.

A patient is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the patient develops acute kidney injury. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage th patient's hypervolemia and hyperkalemia. Which of the following therapies will the patient's hemodynamic status best tolerate?

Continuous venovenous hemodialysis (CVVHD)

-When assessing patients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A) Nerve agent B) Blood agent C) Pulmonary agent D) Vesicant

D

The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding? A) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. B) Inform the physician promptly that there is in imminent leak in the drainage system. C) Encourage the patient to do deep breathing and coughing exercises. D) Document that the chest drainage system is operating as it is intended.

D

A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? A) Psychosocial stress B) Hypersensitivity to an immunization C) Menarche D) Streptococcal infection

D Feedback: Postinfectious causes of postinfectious glomerular disease are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks. Menarche, stress, and hypersensitivity are not typical causes.

- A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second- and third-degree burns, but he is conscious. How would this person be triaged? A) Green B) Yellow C) Red D) Black

D)

A patient is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A) Amyl nitrate B) Dimercaprol C) Erythromycin D) Atropine

D)

The nurse has been notified that the ED is expecting terrorist attack victims and that level D personal protective equipment is appropriate. What does level D PPE include? A) A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots B) A self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical-resistant suit with chemical-resistant gloves and boots. C) The SCBA and a chemical-resistant suit, but the suit is not vapor tight D) The nurse's typical work uniform

D)

The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what? A) Nitrogen narcosis B) Infection C) Impaired diffusion D) Shunting

D) Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types ofrespiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likelybe present at this early stage of recovery and nitrogen narcosis only occurs from breathing compressed

Assist control

Delivers pre-set volumes at a pre-set rate and a pre-set flow rate. Each patient-generated respiratory effort over and above the set rate are delivered at the set volume and flow rate.

A client has been admitted to the medical surgical unit following abdominal surgery for injuries sustained in an explosion.. There is a Jackson Pratt drain with a portable suction unit attached. After 4 hours, the drainage unit is full. What should the nurse do?

Empty the drainage unit

An appropriate nursing intervention for the client following a nuclear scan of the kidney is to:

Encourage high fluid intake

CPAP

Entirely spontaneous breathing Preparation for weaning/extubation

Which of the following substances stimulate the bone marrow to produce red blood cells

Erythropoietin

Symptoms of Chronic Renal Failure

Fluid Accumulation Electrolyte Imbalances- hyperphosphatemia, hypocalcemia Waste Products Retained Acid-base Imbalances Metabolic acidosis Anemia

Heparin drip bleeding

Give protamine sulfate

20. Grafts taken from one body and grafted onto another body are called what? A) Allograft B) Homograft C) Heterograft D) Autograft

Homograft

a patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?

Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis.

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply.

Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nuts Septic shock; infection

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP) Explanation: When ICP increases, Cushing triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

The nurse is providing patient teaching on pancreatic enzyme replacement therapy. What would the nurse tell the patient this therapy is used to treat?

Malnutrition and malabsorption

A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug?

Metoclopramide (Reglan)

DIC Treatments

Packed red blood cells (PRBCs) Cryoprecipitate or fibrinogen concentrates FFP Platelets activated protein C

When assessing the patient with chronic pancreatitis, the nurse anticipates potential dysfunction of which of the following?

Pancreatic islet cells

The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patient's siblings, parents, and grandparents. This assessment addresses the patient's risk of what kidney disorder.

Polycystic kidney disease (PDK)

A patient is receiving heparin for a large venous thromboembolism (VTE). During assessment, the nurse notice a large amount of bright red urine pass through the patient's foley catheter. What intervention should the nurse anticipate first?

Prepare to administer protamine sulfate

When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock?

Progressive

The arterial blood gases for a patient in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?

Rapid and deep

The nurse is reviewing a patient's laboratory results. What findings does the nurse assess that are consistent with acute glomerulonephritis? Select all that apply

Red blood cells in the urine Proteinuria White cell casts in the urine

Nephrotic Syndrome

Results in massive proteinuria, hypoalbuminemia and edema

A nurse is teaching client about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the client correctly identifies which condition as a cause of acute pancreatitis?

Self-digestion of the pancreas by its own proteolytic enzymes

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

A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is a priority for health education?

The need for the child to avoid all foods that have a high potential for allergies

The charge nurse is making assignments for the medical-surgical unit. Which patient would be most appropriate to assign to the new graduate nurse who just completed orientation?

The patient complaining of pain who was diagnosed with diabetic neuropathy

A patient with gastroesophageal reflus disease (GERD) has a diagnosis of Barrett's esophagus with minor cell changes. Which of the following principles should be integrated into the patient's subsequent care?

The patient will require an upper endoscopy every 6 months to detect malignant changes.

A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurse's care of this patient?

The patient's disease is incurable and the nurse's interventions will be supportive.

A patient's neck dissection surgery resulted in damage to the patient's superior laryngeal nerve. What area of assessment should the nurse consequently prioritize?

The patient's swallowing ability

SIMV

Tidal volume is administered only according to rate set (for example, 12 breaths per minute). Patient triggered breaths above set rate allow spontaneous breathing with no additional tidal volume.

Warfarin (Coumadin)

Vitamin K

Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing.

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

What is an early sign of sepsis in the burn injured client?

Widened pulse pressure

The announcement is made that the facility may return to normal functioning after a local disaster. In the emergency operations plan, what is this referred to as? A) Demobilization response B) Post-incident response C) Crisis diffusion D) Reversion

a

The nurse is triaging victims of an earth quake who were removed from a building following its collapse. Which victims should be classified as red? Select all that apply

a 49 year old male with crushing chest pain radiating to the jaw, is diaphoretic, nauseated, and has an open fracture of the left wrist. AND a 75 year old female with obvious fracture of the femur, absent pedal pulses on the affected side, heart rate 100bpm, respirations 34 breaths/min, skin diaphoretic; awake/alert, states pain is a 10 on a scale of 1 to 10.

A patient is being treated in the ED following a terrorist attack. The patient is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this patient has been exposed to what chemical agent? A) Nerve agent B) Pulmonary agent C) Vesicant D) Blood agent

a)

The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A) Epistaxis B) Periorbital edema C) Bruising over the mastoid D) Unilateral facial numbness

c

A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as

coma

While snowboarding, a fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? concussion laceration contusion skull fracture

concussion

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? a) Occipital skull fracture b) Temporal skull fracture c) Frontal skull fracture d) Basilar skull fracture

d

The nurse is triaging victims of an earthquake who were removed from a building that collapsed in the earthquake. Which of the following victims should be classified as red? Select All That Apply Select one or more: a. An 80 year old who has multiple facial lacerations and a second degree burn on the left forearm. b. A 32 year old female who is unconscious, 3 inch laceration to the forehead, ecchymosis behind the ears, respiratory rate 6, pulse is weak and thready. No breath sounds on the right c. A 10 year old male with crushing chest wound, tachypnea with labored breathing, unconscious, impaled object in forehead. d. A 49 year old male with crushing chest pain radiating to the jaw, is diaphoretic, nauseated, and has an open fracture to the wrist. e. A 75 year old female with open fracture of the femur, absent pedal pulses on the affected side. Heart rate 110, respirations 34, skin diaphoretic and cool, states pain is 10 on 1-10 level

d, e

Chronic Glomerulonephritis

hypoalbuminemia proteinuria

Respiratory failure is a syndrome in which one of the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. Therefore, it can be classified as

hypoxemic of hypercapnic.

A central line is inserted by the medical resident on an older adult client diagnosed with oral cancer. During the insertion, the nurse assesses the client's sudden shortness of breath. What does this symptom indicate?

pneumothorax

In decorticate posturing,

the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Escharotomy

to relieve pressure from eschar formation; prevent compartment syndrome from burn circumferential constriction about the chest or extremities