Medsurge2 week7
Which of the following advice should the nurse give a client with dermatitis until the etiology of the dermatitis is identified?
"All family members need to be treated."
A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage?
"Apply sunscreen even on overcast days."
The nurse is concerned about the aggressive behavior of a hospitalized client. What intervention(s) can decrease the risk of harm to staff members? (Select all that apply.)
-Notify security and administration of the potential for violence. -Keep the client in view at all times. -Approach with a calm but firm demeanor with support from colleagues.
Nursing students taking a class on public health and safety are reviewing the progression of symptoms in the event of a smallpox attack. Place in order the sequence of signs and symptoms that would occur in an infected client.
-Symptoms develop, such as high fever, headache, body aches, and malaise. -Rash appears on the tongue and in the mouth and develops on the face and spreads to the arms, legs, and feet. -Rash becomes raised papules that fill with fluid, with a depressed central area resembling a navel. -Papules become pustules that are round and firm, as though embedded with pellets. -Pustules begin to crust and scab, with shedding over a 3-week period, leaving pitted scars.
All people who have household or face-to-face contact with the patient diagnosed with smallpox after the fever begins should be vaccinated within what timeframe to prevent infection and death?
4 days
The nurse is changing the dressing of a chronic wound. There is no sign of infection or heavy drainage. How long will the nurse leave the wound covered for?
48 to 72 hours
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?
5% albumin
The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.
60 mm Hg
The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?
70%
A patient is admitted to a burn treatment center at 2:30 p.m. with full-thickness burns over 40% of his body. The injury occurred at 1:30 p.m. at a paper-making plant. The nurse knows that burn shock has to be prevented or treated. Based on fluid volume shifts, the nurse knows that fluid loss would peak by __________ to __________ hours, with the greatest volume being lost from __________ to__________ hours after the burn.
7:30 p.m. to 9:30 p.m.; 24 to 36 hours
Colloids are used to expand intravascular volume in fluid replacement therapy. The nurse monitors the central venous pressure (CVP) reading and continues fluid replacement to achieve a reading of:
8 to 10 mm Hg.
The nurse is calculating a patient's mean arterial pressure (MAP). What is the patient's MAP, if the blood pressure is 110/70 mm Hg?
83
A critical care nurse should be able to quickly assess a patient's mean arterial pressure (MAP) when monitoring cardiac status. Using the standard formula, estimate the MAP of a patient whose blood pressure is 110/70 mm Hg.
83 mm hg
You are the nurse caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms. You know that these clients would be classed as being victims of which of the following?
A biologic disaster
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers
A continuous infusion of total parenteral nutrition
Which assessment finding indicates an increased risk of skin cancer?
A deep sunburn
A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:
A myocardial infarction.
The disaster team in your region is responding to a local chemical plant leak. They are required to wash exposed areas of the victim's skin with a solution containing bleach and then flushed with plain water. What have these victims been exposed to?
A nerve agent
You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?
A rapid, bounding pulse
Morphine sulfate has which of the following effects on the body?
Reduces preload
Which of the following is a true statement regarding the purposes of skin grafts?
Reduces scarring and contractures.
The client in the intensive care unit reports constantly feeling tired and not getting enough rest. The nurse best intervenes to promote sleep for this client by
Reducing lights and noise present in the client's room at bedtime
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?
A urinary output of 30 mL/hr
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?
A urine output consistently above 40 ml/hour
The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing?
Adduction
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?
Administer an analgesic as ordered.
The nurse is caring for a patient with extensive bullous lesions on the trunk and back. Prior to initiating skin care, what is a priority for the nurse to do?
Administer analgesic pain medication.
It has been more than 3 days since the client had his last bowel movement while hospitalized in the intensive care unit. The client reports discomfort and bloating. The nurse notes the client's abdomen is distended. A nursing intervention that would immediately address the problem is:
Administering a phosphate/biphosphate enema (Fleet enema)
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next
Administers oxygen by nasal cannula at 2 liters per minute
The client is admitted to an intensive care unit and is being mechanically ventilated. To best prevent gastrointestinal bleeding associated with stress ulcers, the nurse
Administers pantoprazole 40 mg intravenously every day
You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client?
Adrenergic drugs
A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits
Adventitious breath sounds
The nurse observes for fluid and electrolyte changes during the acute phase based on the knowledge that fluid remobilization usually begins:
After 48 to 72 hours later, when fluid is moving from the interstitial to the intravascular compartment.
When working in an acute care facility as part of a disaster response team, a nurse is preparing to care for clients requiring level C protection. Which of the following would the nurse need to wear?
Air-purified respirator
Which of the following colloids is expensive but rapidly expands plasma volume?
Albumin
Industrial trauma resulted in the transport of a client to your ED. Enroute, his systolic BP was 98 and sinking. Which systolic BP supports the diagnosis of shock?
All options are correct
Nursing students are reviewing the various weapons of mass destruction, specifically biologic agents. The students demonstrate understanding of the information when they identify which of the following as the most likely weaponized agent?
Anthrax
A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions?
Antiviral
Which of the following is an example of a valvular cardiac disease?
Aortic stenosis
Which of the following measures can be used to cool a burn?
Application of cool water
An alarm has reached your ED regarding a serious MVA between a full tour bus and a school bus - the number of casualties expected is quite high. As you reach the site and being your assessments, you find many abrasions and lacerations. Which of the following nursing interventions are required to maintain the skin integrity when caring for clients in disaster situations?
Apply a semiocclusive dressing over the wound
As a nurse on a pediatric unit you spend a significant amount of time teaching parents the correct techniques for medicating their children and family members. What is an important piece of education when applying topical medications?
Apply exactly as directed
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?
Apply firm pressure over the involved area or artery.
In a client with burns on the legs, which nursing intervention helps prevent contractures?
Applying knee splints
Hypovolemia and hypoperfusion in burn shock cause an electrolyte imbalance that has a significant influence on morbidity unless treated. Which of the following lab results reflects that condition?
Plasma lactate of 6 mEq/L
The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in?
Priority 1
A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client?
Private room
Dry, rough, scaly skin with the presence of itching is best described as:
Pruritus
Photochemotherapy has been used as a treatment for which of the following skin disorders?
Psoriasis
A patient is diagnosed with psoriasis after developing scales on the scalp, elbows, and behind the knees. The patient asks the nurse where this was "caught." What is the best response by the nurse?
Psoriasis is an inflammatory dermatosis that results from an overproduction of keratin.
A patient visits a clinic for assessment of an inflammatory skin disorder. The nurse diagnoses the condition as psoriasis based on the appearance of the skin. Which of the following describes the dermatoses?
Red, raised patches of skin covered with silvery scales
The nurse is caring for the client with decreased secretion of antidiuretic hormone (diabetes insipidus). What medication does the nurse anticipate administering for the treatment of diabetes insipidus?
Arginine vasopressin
An alarm has reached your ED regarding a serious MVA between a full tour bus and a school bus — the number of casualties expected is quite high. While part of your staff is sent to the accident site, the remaining staff readies your unit for mass traumas. At the accident site, your practice begins. As a nurse, what would you expect as your top priority?
Assess as many victims as possible at the site
The client has a history of ventricular fibrillation responding poorly to medications and an implantable cardioverter-defibrillator (ICD). The client is now admitted to the intensive care unit following abdominal surgery and is in stable condition. The nurse plans to (select all that apply):
Assess vital signs every hour. Monitor the rhythm strip. Maintain a peripheral intravenous access.
A client is being treated for cyanide exposure. The nurse would least likely expect which agent to be used as part of the client's treatment?
Atropine
A patient is diagnosed with seborrheic dermatitis on the face and is prescribed a corticosteroid preparation for use. What should the nurse educate the patient about regarding use of the steroid on the face?
Avoid using the medication around the eyelids because it may cause cataracts and glaucoma.
Diagnosis of skin cancer is confirmed by which of the following diagnostic tests?
Biopsy
During a mass casualty event, a person whose injuries are extensive and whose chances of survival are unlikely even with definitive care would receive which color tag?
Black
Which of the following clinical manifestations occur in cardiogenic shock?
Blood pressure falls
Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:
Blood pressure.
A critical care nurse knows to assess the cardiac system for the probable cause of heart disease subsequent to trauma. Which of the following is a major concern?
Cardiac tamponade
An adolescent presented to the emergency department with increasing frequency of seizures. The client has a history of epilepsy and has been taking carbamazepine (Tegretol) as prescribed. It is most important for the nurse to
Check the blood level of carbamazepine.
A patient was suspected of being in direct contact with anthrax but is exhibiting no signs or symptoms. What type of prophylaxis does the nurse know this patient will have to take?
Ciprofloxacin (Cipro) for 60 days
You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock?
Circulatory (distributive)
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?
Circulatory (distributive)
Which of the following is known as the universal distress signal?
Clutching of the neck
The nurse recommends which of the following types of therapeutic baths for its antipruritic action?
Colloidal (Aveeno, oatmeal)
The client, who does not have diabetes, is in the intensive care unit. Orders have included to check the client's blood glucose level before each meal and to implement an 1800 calorie/day diet. The nurse notes the blood glucose levels for the past 3 days shown in the accompanying image. The best action of the nurse is to:
Consult with the health care provider about insulin coverage.
the client's blood glucose level before each meal and to implement an 1800 calorie/day diet. The nurse notes the blood glucose levels for the past 3 days shown in the accompanying image. The best action of the nurse is to:
Consult with the health care provider about insulin coverage.
A client who has undergone brain surgery is in the intensive care unit and being kept in a chemically induced coma. The client has no spontaneous ventilation. The physician has ordered ventilator settings at a set tidal volume of 700 and a set rate of 16. What type of ventilator mode is this considered?
Controlled mandatory ventilation
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:
Epidermis and a portion of deeper dermis.
A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm?
Epinephrine
For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority?
Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries.
Medical and nursing interventions for patients who present with multiple injuries follow a sequence of treatment priorities. Which of the following is the first priority of care?
Establish an airway.
The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED?
Establishing an airway.
The patient is advised to apply a suspension-type lotion to a dermatosis site. The nurse should advise the patient to apply the lotion how often to be effective?
Every 3 hours
A dermatologist recommends an over-the-counter suspension to relieve pruritus. The nurse advises the patient that the lotion should be applied:
Every 3 to 4 hours for sustained effectiveness.
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?
Full-thickness
Which type of burn injury requires skin grafting?
Full-thickness
A client has developed shock as the result of the MVA. His treatment is focused on preventing the development of more than one type of shock and to minimize the effects of the type of shock he is demonstrating. Which of the following is NOT a category of shock?
Hepatic
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
Hoarseness of the voice
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?
Homografts
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction which is:
Hyperkalemia.
Which of the following is to be expected soon after a major burn? Select all that apply.
Hypotension Tachycardia Anxiety
Which of the following is a possible cause of decreased preload?
Hypovolemia
The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?
Identification by the destruction of the dermis and epidermis
A child tips a pot of boiling water onto his bare legs. The mother should:
Immerse the child's legs in cool water.
Which of the following reflect the pathophysiology of cutaneous signs of HIV disease?
Immune function deterioration
A nurse is providing care to a client who has been exposed to phosgene vapor. Which nursing diagnosis would the nurse identify as the priority?
Impaired gas exchange related to destruction of the pulmonary membrane
A nurse in a health care provider's office teaches a patient how to apply an occlusive dressing (using plastic film) to cover a medicated ointment applied to her arm. An important teaching point would be to tell the patient to:
Limit use of the dressing to 12 hours.
A patient has experienced blunt abdominal trauma from a motor vehicle crash. The nurse assesses the patient, knowing that which organ is the most frequently injured solid abdominal organ?
Liver
A patient experienced a penetrating intra-abdominal injury due to a motor vehicle crash. The nurse knows to carefully assess the upper right abdominal quadrant based on her knowledge that the most frequently injured solid abdominal organ is the:
Liver.
The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following?
Low
A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess
Lung sounds
In a client who has been burned, which medication should the nurse expect to use to prevent infection?
Mafenide (Sulfamylon)
A soldier is preparing to enter an area in which there is a high risk for chemical exposure to a nerve agent. What should the soldier be given prior to entering this area?
Mark I automatic injectors that contain 2 mg atropine and 600 mg pralidoxime chloride
A patient in shock would exhibit which one of the following clinical findings?
Metabolic acidosis
During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injuries?
Minor and treatment can be delayed hours to days
A nurse is providing care to a client who was exposed to a nerve agent. Which of the following would the nurse most likely assess?
Miosis
Which positioning strategy should be utilized for the patient diagnosed with hypovolemic shock?
Modified Trendelenburg
While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply?
Moist sterile saline gauze
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?
Monitor vital signs and oxygen saturation every 15 to 30 minutes.
Which of the following is the analgesic of choice for burn pain?
Morphine sulfate
The nurse is caring for a client with a line in the right radial artery. Which assessment finding by the nurse indicates a complication from the arterial line?
Pale fingers with sluggish capillary refill
The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?
Paralytic ileus
The nurse teaches the patient who demonstrates herpes zoster (shingles) that
the infection results from reactivation of the chickenpox virus.
Following a disaster, a client's condition is serious, but she is stable enough to survive if treatment is delayed 6 to 8 hours. What category of triage would the nurse place this client?
yellow
A client with atopic dermatitis is ordered a potent topical corticosteroid to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?
Related to percutaneous absorption of the topical corticosteroid
The client is hospitalized following a suicide attempt. A staff member is present in the client's room for one-on-one observation and requests to take her mandatory work break. The best intervention by the nurse is to:
Remain in the client's room while the staff member is on break.
A patient is scheduled for Mohs' microscopic surgery for removal of a skin cancer lesion on his forehead. The nurse knows to prepare the patient by explaining that this type of surgery requires:
Removal of the tumor, layer by layer.
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:
Replace lost fluids and electrolytes.
Which of the following interventions help minimize risk of further injury to an affected person at a scene of a fire? Choose all correct options.
Roll the client in a blanket Place the client in a horizontal position
A patient is being treated for septic shock. On assessment, the nurse notes an abnormal finding that is reported to the health care provider. Which of the following is most likely that finding?
SVO2 of 55%
A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect?
Scabies
With repeated reactions of contact dermatitis, which of the following can occur?
Secondary bacterial infection
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
The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock?
Septic
A 57-year-old client has been brought to your ED via squad. He is unresponsive and his wife is presenting his recent history. She reports his symptoms of elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. His labs show an elevated WBC; cultures are forthcoming. Why is time of the essence in treating this client's condition?
Septic shock is the deadliest form of shock
When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific patient management and medications to combat the virus, bacteria, or toxin. Which of the following statements reflect the patient management of variola virus (smallpox)?
Smallpox spreads rapidly and requires immediate isolation.
A client has been exposed to a vesicant and is undergoing decontamination. Which of the following most likely would be used?
Soap and water
An adolescent is brought to the ED after a vehicular accident and is pronounced dead on arrival (DOA). When the parents arrive at the hospital, what is the priority action by the nurse?
Speak to both parents together and encourage them to support each other and express their emotions freely.
The nurse inspects the appearance of a sacral ulcer and documents "a shallow open ulcer with a red-pink wound with partial thickness loss of dermis." The nurse knows to classify this ulcer as:
Stage II.
A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?
Stage III
Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent?
Sulfadiazine, silver (Silvadene)
The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?
Sulfadiazine, silver (Silvadene)
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?
Superficial
The client has been in the intensive care unit for 5 days and has not been out of bed. To implement mobilization for the client, the nurse
Supports the client while the client bears own weight
Which of the following materials consists of a powder in water?
Suspension
When a patient is in the compensatory stage of shock which of the following symptoms occurs?
Tachycardia
Which of the following clients has an immediate need for intubation and mechanical ventilation?
The client demonstrates ascending paralysis with diminished breath sounds 1 week following a gastrointestinal illness.
The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?
The patient has developed a stress ulcer that is bleeding.
The nurse is listening to the lung sounds of an intubated client and hears them only on the right. What does the nurse understand might have occurred?
The physician intubated the right main stem bronchus.
Which of the following is accurate regarding topical antibacterial therapy?
They are effective against gram-negative organisms.
When working with an elderly patient, the nurse would most likely notice which of the following changes?
Thinning of epidermis
A minor burn injury is classified by which of the following?
Third degree burn of <2% total body surface area (TBSA) not involving special-care areas
Which term describes a fungal infection of the scalp?
Tinea capitis
You are caring for clients who have been exposed to a toxic nerve agent. You will need to use diazepam with these clients. Why is diazepam given when managing the effects of toxic nerve agent toxicity?
To control possible seizures
What would the nurse identify as the primary purpose of the insertion of an intra-aortic balloon pump (IABP) in the client who has heart damage following a myocardial infarction?
To decrease the workload of the heart and improve organ perfusion
Which of the following is defined as the potential of an agent to cause injury to the body?
Toxicity
Which of the following statements reflects the nursing management of pulmonary anthrax (B. anthracis)?
Treatment with ciprofloxacin or doxycycline is suggested after exposure.
The client has a ventricular assist device (VAD) for class IV heart failure. It is most important for the nurse to make the following assessment every hour:
Urine output
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?
Urine output of 20 ml/hour
What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?
Use strict hand hygiene techniques.
A nursing instructor is describing the role of a nurse during a disaster. Which of the following would best reflect the nurse's role?
Variable depending on the needs of the situation
Which medication order would the nurse question for a client with a blood pressure of 180/110?
Vasopressin
Which of the following is the maximum amount of air that can be expelled after a maximum inhalation?
Vital capacity
Which of the following terms is the tendency for a chemical to become a vapor?
Volatility
A patient who was recently diagnosed with pruritus on the chest and back is given information about skin care and bathing. The most important advice on cleansing is to avoid:
Washing with soap and hot water.
Which of the following advice should the nurse give a client with dermatitis until the etiology of the dermatitis is identified?
Wear rubber gloves when in contact with soaps.
Which of the following is the most likely weaponized biological agent available?
anthrax
To prepare the community for the possible threat of anthrax, a nurse must teach that:
anthrax can infect the integumentary, GI, and respiratory systems.
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's:
blood pressure.
The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to
decrease catabolism.
The nurse has provided care to a client she has determined may be exhibiting signs of depression. The nurse has reviewed reasons for the client's depression and suspects a prescribed medication may be causing it. Which of the following medications could be a contributor to the client's depression?
metoprolol (Toprol)
Upon completion of the insertion of an intra-aortic balloon pump (IABP), what is the priority nursing assessment?
monitor cardiac functions
Man-made chemical disasters have been portrayed in movies and on television - nightmarish situations, at best. Of the chemical disasters discussed which is the most toxic?
nerve agents
The client is receiving ventilation through a spontaneous bi-level positive airway pressure (BiPAP) device. The nurse
observes the client to ensure the device delivers a breath when the client initiates it
A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:
pain management.
Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage?
priority 4
The client is on a mechanical ventilator and has been on bedrest since admission to the intensive care unit following surgery. Prior to assisting the client to a bedside chair, it is most important for the nurse to assess the client's
pulse and blood pressure
A nurse who is working as part of a disaster response team is performing triage at a mass casualty incident. One of the victims has a sucking chest wound. The nurse would triage this client using which color-coded tag?
red
The NATO triage system uses color-coded tagging to identify severity of injuries. A patient with survivable but life-threatening injuries (i.e., incomplete amputation) would be tagged with which color?
red
Which of the following solutions should the nurse anticipate for fluid replacement in the male patient?
Lactated Ringer's solution
Which of the following is the preferred IV fluid for burn resuscitation?
Lactated Ringer's (LR)
The amount of blood pumped to the body each minute is known as cardiac output. Using a stroke volume of 70 mL, which one of the following heart rates would yield a cardiac output outside the normal range?
110 bpm
A patient has a moisture-retentive dressing for the treatment of a sacral decubitus ulcer. How long should the nurse leave the dressing in place before replacing it?
12 to 24 hours
A physician orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
"To prevent evaporation of water from the hydrated epidermis."
The client was admitted with severe abdominal pain and nausea and vomiting. Initially, the client was placed NPO for 24 hours. The client will be started on feedings now. To promote ingestion of food, the nurse intervenes prior to the meal by: (Select all that apply.)
-Administering ondansetron (Zofran) 4 mg IV -Sitting the client in a bedside chair -Asking and providing food preferences
The unstable client is on a mechanical ventilator. To prevent venous thromboembolism, the nurse intervenes by which of the following measures? (Select all that apply.)
-Applying a sequential compression device to the client's legs -Administering prescribed heparin 5000 units subcutaneously every 12 hours -Performing passive range-of-motion exercises to the legs every 2 hours
A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)
-Assess and document any bruises and lacerations. -Record a history of the event, using the patient's own words. -Label all torn or bloody clothes and place each item in a separate brown bag so that any
A nurse working as part of a disaster response team is triaging clients. Which of the following clients would the nurse color code as green? Select all that apply.
-Client with a fractured arm -Client with a first-degree burn to the forearm
Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply.
-Lansoprazole (Prevacid) -Famotidine (Pepcid) -Ranitidine (Zantac)
A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply.
-The client who is in the first 15 minutes of receiving 1 unit of PRBCs -The 55 year-old client with spina bifida -The client who reports an allergy to peanuts that causes throat swelling
The client has an endotracheal tube and is receiving positive-pressure ventilation. To maintain a clear airway, which of the following actions does the nurse perform? (Select all that apply.)
-Turn the client every 2 hours. -Provide mouth care every 4 hours. -Suction the client through the endotracheal tube as needed. -Auscultate lung sounds every hour.
When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.)
-Urinary output -Mental status -Vital signs
The palm represents which percentage of a person's TBSA?
1%
A patient, an average-built male adult, was brought into the ED via ambulance with significant bleeding from an abdominal gunshot wound. The health care provider diagnosed a class IV hemorrhage. The nurse knows this refers to a blood volume loss of at least _____ mL, which is equivalent to about a _____ % loss of blood volume using 6 L of blood volume.
2,400 mL: 40%
A nurse is assigned to care for a 75 kg male patient on a high-frequency, volume-cycled ventilator that delivers very small tidal volumes (3 to 6 mL/kg). The nurse is responsible for monitoring the ventilator. What is the correct tidal volume delivery for a 75 kg patient?
225 to 450 mL
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?
27%
Permanent brain injury or death will occur within which time frame secondary to hypoxia?
3 to 5 minutes
A client has experienced burns covering the back and front of both legs. Using the Rule of Nines, what percentage would the nurse assign to the client's injury when documenting? Fill in the blank with a number.
36
A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?
36%
Which of the following medication classifications may be used for contact dermatitis?
Corticosteroids
Which of the following aggravates the condition caused by acne vulgaris?
Cosmetics
Which of the following is a procedure done in emergency situations when endotracheal intubation is not possible?
Cricothyroidotomy
Which of the following terms refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery?
Crush injuries
A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus?
Decreased peristalsis
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis?
Deep partial-thickness
A patient was involved in an avalanche that killed many people on a ski trip, including the patient's brother. The nurse is educating the patient about recognition of stress reactions and ways to manage stress. What type of process is the nurse introducing to the patient?
Defusing
When describing the use of smallpox as a biologic agent, which of the following would the nurse include as the primary means of infection?
Direct contact
A client with a fractured hip is admitted through the emergency department. Past medical history includes a right mastectomy. The nurse notes a peripheral intravenous catheter has been inserted in the right hand. The nurse first intervenes by
Discontinuing the intravenous site and starting a new site in the left arm
A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as:
Dry and pale white.
Which of the following is an example of a topical anesthetic?
EMLA cream
Within the burn unit, you must be continually aware that clients may develop potential complications based upon the type of burn they endured. Which burns have a common complication of cardiac dysrhythmias?
Electrical
Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment?
Emergent
A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to
Encourage the family to touch and talk to the client.
A nurse is working with a group of disaster victims to reduce the psychological effects of the trauma. Which of the following would be least helpful?
Encouraging the victims to watch television replays of the event.
Which of the following nonsedating antihistamines is appropriate for daytime pruritus?
Fexofenadine (Allegra)
Inhalation of anthrax mimics which disease process?
Flu
A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do?
Have someone assist him into a bath of cool water, where he can wait for emergency personnel.
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?
Head injury
You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?
In the compensation stage, catecholamines are released.
Hemodynamic monitoring in critical care includes assessing the effects of preload. The critical care nurse understands that increased preload is associated with which of the following causes? Select all that apply.
Increased fluid volume Vasoconstriction
You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client?
Increases myocardial contractility
The client is hospitalized in the intensive care unit and frequently uses the call light system for nonsensical requests. The nurse intervenes best by:
Increasing time spent with the client
Development of malignant melanoma is associated with which of the following risk factors?
Individuals with a history of severe sunburn
Which zone of burn injury sustains the most damage?
Inner
Which of the following site is the source of most microbes leading to bacterial infection?
Intestinal tract
A person suffering from carbon monoxide poisoning would exhibit which of the following manifestations?
Intoxication
The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?
Intravenous
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water.
A patient is being evaluated for nodular cystic acne. What systemic pharmacologic agent may be prescribed for the treatment of this disorder?
Isotretinoin (Accutane)
Which of the following infecting agents is the cause of scabies?
Itch mite
A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction:
Jugular venous distention
The nurse assesses the patient and observes reddish-purple to dark blue macules, plaques and nodules. The nurse recognizes that these manifestations are associated with which of the following conditions?
Kaposi's sarcoma
For a patient in hypovolemic shock, which type of fluid is used initially?
Lactated Ringer's
The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?
Narrowed pulse pressure
The nurse is assessing the client with hypothyroidism. What clinical manifestations does the nurse expect to find?
Nervousness
Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock?
Neurogenic
A client has requested that if respiratory failure is imminent, he not be intubated and placed on a ventilator; however, he will accept other methods of ventilatory support. What other option would be available for this client?
Noninvasive positive pressure methods of oxygen delivery
Which category of the traditional triage system is reserved for patients who do not have life-threatening illnesses?
Nonurgent
A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:
Oxygen at 2 L/min by nasal cannula
The nurse has assessed the client for any impairment to the client's skin upon admission. What data about the client place the client at risk for a pressure ulcer?
The client has experienced nausea and vomiting for 3 days.
You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately?
The client's heart rate is greater than 90 beats per minute.
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?
The client's urinary output is 0.5 mL/kg/hour.
A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?
The early appearance of the burn injury may change.
The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply.
The face The perineum
A nurse administers amiodarone to a client. What clinical assessment findings would indicate that the medication has achieved its desired effect?
The heart rate decreases.
A patient has just received a gastric tube for feedings. Its placement in the stomach must be verified. Which of the following is the most accurate method?
X-ray visualization of the tube tip
The clinic nurse is triaging a client who had visited a smallpox affected community 14 days ago. The client has developed a fever but no rash. Should the nurse consider the client at risk for smallpox?
Yes, fever and rash may follow 14 asymptomatic days.
A nurse knows that the major clinical use of dobutamine (Dobutrex) is to:
increase cardiac output.