Hurst Elevate Module 1

The nurse is caring for a client 8 hours post colectomy who is receiving 40% humidified oxygen. ABG results are: pH= 7.30, pO2= 91, pCO2= 50, HCO3= 24. Based on this information, which nursing action should the nurse initiate? 1. Reposition the client every 2 hours. 2. Request respiratory therapy to perform postural drainage and percussion. 3. Increase oxygen percentage. 4. Initiate incentive spirometry. 5. Assess mental status.

1, 4, & 5 If you have a colectomy, would you be taking deep breaths? No, so you would be retaining CO2, which makes pH go down. These interventions improve gas exchange.

What is the nurse's first priority when treating a client admitted with a high voltage electrical burn? 1. Attach client to a cardiac monitor. 2. Establish IV access of Normal Saline 3. Administer fentanyl (1 mcg/kg) IV 4. Apply antibiotic ointment and dressing to burns

1. Correct: The priority action in treating a high voltage electrical burn is to monitor the client's cardiac status. Place the client on a cardiac monitor because the client is at risk for arrhythmias.

The client has pustules on the arm from intravenous drug abuse. The microbiology laboratory informs the nurse that the client's cultures are growing methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? 1. Cover the pustules to prevent drainage. 2. Implement contact precautions immediately. 3. Instruct the client on the importance of hand hygiene. 4. Inform the client to wear a mask when ambulating in the hall. 5. Instruct visitors to wash hands before entering the client's room.

1., 2., 3. & 5. Correct: The pustules should be covered with a dressing, because MRSA is transmitted via contact! It is important that the nurse implement these interventions in order to prevent the spread of infection. The number one way to prevent the spread of infection is handwashing. That includes the client, staff, and visitors. If the client refuses to follow instructions, then isolation precautions are warranted.

The nurse is caring for a client admitted to the unit with heart failure. Upon entering the room, the nurse notes that the client is agitated, gasping for air, and attempting to sit up. The client states "I can't get my breath". What actions should the nurse take? 1. Elevate the head of the bed to sitting position 2. Dangle client's legs over side of the bed 3. Initiate oxygen at 2 liters per nasal cannula 4. Initiate IV of lactated ringers 5. Administer morphine 2 mg IV

1., 2., 3., & 5. Correct: The first thing the nurse should do is to sit the client up. This allows for better chest expansion, thereby improving pulmonary capacity. By dangling the legs, blood is pooling in the periphery. This decreases the circulating blood volume so that the heart does not have to work as hard and blood will then go in a forward direction rather than going backward to the lungs. Oxygen increases available oxygen for myocardial uptake to combat effects of hypoxia. Morphine decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety.

What should the nurse assess when examining a client who has had a fasciotomy of the arm? 1. Airway 2. Capillary refill 3. Color 4. Level of consciousness 5. Proximal pulses 6. Sensation

2., 3., & 6. Correct: Fasciotomy is a surgical procedure that cuts away the fascia to relieve tension or pressure. So after the procedure, the nurse wants to make certain that pressure has been relieved and circulation distally is good. The nurse will thus need to monitor skin color, capillary refill, distal pulses, and sensation. Since this is a surgical procedure, bleeding will also need to be monitored.

A client arrives at the emergency department (ED) after sustaining a high-voltage electrical injury. Which interventions should the nurse initiate in the ED? 1. Determine body surface area injured using the Lund and Browder Method. 2. Draw blood for cardac enzymes. 3. Infuse Lactated Ringers to maintain hourly urine output between 75-100 mL/hr. 4. Obtain 12 lead electrocardiogram (EKG). 5. Remove nonadherent clothing.

2., 3., 4 & 5. Correct: Electricity kills vessels, nerves, and organs. So the heart can be damaged. We need to assess damage by drawing blood for cardiac enzymes and EKG. Large bore IV access and large volume fluid resuscitation is important in patients with anything more than a very minor low voltage injury. Titrated to produce adequate urinary output (75-100) Remove nonadherent clothing so that proper inspection and care can be provided.

A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.33, PaCO2 = 49, HCO3 = 26, O2 = 92%. What medication could have contributed to these blood gases? 1. Furosemide 2. Chloral hydrate 3. Heroin 4. Methadone 5. Methylphenidate 6. Tramadol

2., 3., 4., & 6. Correct: These medications decrease the respiratory rate, causing respiratory acidosis.

A client was admitted 24 hours ago in septic shock. Treatment included oxygen at 40% per ventimask, IV therapy of Lactated Ringer's (LR) at 150 mL/hr, vancomycin 1 gram IV every 8 hours, and methylprednisolone 40 mg IVP twice a day. Which clinical data indicates to the nurse that further treatment is necessary? 1. Blood pressure 96/68; HR 98; RR 20 2. WBC 12,000/mm3 (12 x 10^9)/L 3. CVP- 3 mmHg 4. pH- 7.30; pCO2- 44; pO2 -92; HCO3- 20 5. Urinary output of 150 mL/8 hours

2., 4., & 5. Correct: The client's white blood cell count is elevated. This means the client is still sick and needs further therapy. The client is still in metabolic acidosis, so no improvement. Urinary output should be adequate if treatment is successful. The urinary output should be 30 mL/hr for an adult. What is it for this client? 150 mL over 8 hours or 18.75 mL/hr.

A client is admitted for treatment of fluid volume excess. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. Which prescription would be of concern to the nurse? Labs: Sodium 136 Potassium 3.9 Calcium 9.0 Glucose 108 Prescriptions: Bedrest 2 gram Na diet IV infusion of Normal Saline at 75 mL/hr Furosemide 20 mg IVP every morning Potassium Chloride (KCL) 20 mEq by mouth twice a day Answers: 1. Diet 2. Furosemide 3. IV infusion 4. Potassium Chloride (KCL)

3. Correct: The client is in a fluid volume excess. The IV prescription is for normal saline, which is an isotonic solution. What will this fluid do? Stay in the vascular space, worsening the problem.

An intubated client has been admitted to the emergency department via ambulance with sustained burns to the upper torso, face, and neck as a result of a steam injury. Which intervention is the nurse's priority? 1. Administer 1000mL of lactate ringers (LR) over 1 hour. 2. Connect endotracheal tube to a ventilator. 3. Elevate head of bed to 35 degrees. 4. Connect to cardiac monitor

3. Correct: What happens with burn injuries. Swelling. Elevating the head of the stretcher will help to decrease swelling. Since the client is already intubated, this would be the nurse's first action on arrival.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? Values: pH - 7.46 PaCO2 - 32 HCO3 - 22 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4., & 5. Correct: Answer: Uncompensated respiratory alkalosis

A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that treatment has been successful? 1. BP 120/70 lying; 98/68 standing 2. Bounding pulses 3. One day weight gain of 5 kg 4. Urine specific gravity of 1.010 5. Serum sodium 145 mEq (145 mmol/L)

4., & 5. Correct: With fluid volume deficit, the specific gravity can be expected to be abnormally high. This urine specific gravity is normal. This is a normal sodium level.

The nurse is assigned to care for 4 adult clients. In what order should the nurse care for these clients? Put in the order of Priority: - Client who is to receive an analgesic 30 min prior to wound debridement in 2 hours. - Client admitted with electrical burns 4 hours ago and has a serum potassium level of 5.7 - Pt admitted with facial burns 3 days ago who has been crying since since recent visitors left. - Client admitted with partial thickness arm burns who has temperature of 99.F and a blood pressure of 92/66

The client admitted with electrical burns 4 hours ago and has a serum potassium level of 5.7 mEq/L . he client with partial thickness arm burns who has a temperature of 99°F (37.2°C) and a blood pressure of 92/66. The client who is to receive an analgesic 30 minutes prior to wound debridement in 2 hours. The client with facial burns 3 days ago who has been crying since recent visitors left.

A nurse arrives at the scene of a home fire along with local emergency medical services (EMS) to find a client lying in the front yard. Burns are noted to the face, neck and chest. In what order should the nurse care for this client at the scene? Put these in the Correct order: - Remove restrictive objects. - Assess breathing - Administer 100% humidified oxygen - Assess breathing - Establish airway patency

This is the correct emergency procedures at the burn scene. First, establish airway patency. Second, assess breathing. Third, administer 100% humidified oxygen. Fourth, soak burned area with cool water. Fifth, remove restrictive objects.