Sole 11, 20, 21

The nurse is assisting the patient who is recovering from moderate burns to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals?

"Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to hel"

The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the primary healthcare pcp best indicates the nurses knowledge of pain management for this patient?

"The patient's pain varies depending on the treatment agbiivrbe.cno.mC/teasnt we try patient-controlled analgesia to see if that helps the patient better?"

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 would be the nurse's best response?

"Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound."

rhabdomyyolysis urine output

100ml/hr

A patient who weighs 154 pounds has a burn injury that covers 50% of body surface area. The nurse calculates the intravenous (IV) fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula. The nurse plans to administer what amount of fluid in the first 24 hours?

14L

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? What is the priority intervention in the plan of care?

Active and passive range of motion every hour

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.)

Additional pain medication may be needed because of rapid body metabolism. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. Patients with a history of drug and alcohol abuse will require higher doses of pain medication.

Which infection control strategy should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.)

Apply topical antibacterial wound ointments/dressings. Daily assess the need for central IV catheters. Maintain strict aseptic technique during burn wound management.

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which intervention? (Select all that apply.)

Applying splints that maintain the extremity in an extended position Implementing passive or active range-of-motion exercises Wrapping fingers and toes individually with bandages

When doing manual ventilations during a code, the nurse would administer ventilations following which guideline?

Approximately 8 to 10 breaths per minute

An elderly individual from an assisted living facility (ALF) presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do to best achieve an accurate history of the event?

Ask the caregiver to step out while examining the patieabnitrb'.scobmu/trenst injury.

The code team has just defibrillated a patient in ventricular fibrillation. Following CPR for 2 minutes, what is the next action to take?

Assess rhythm and pulse.

Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.)

Bedrest Burns to lower extremities Delayed fluid resuscitation

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. What is a primary nursing diagnosis for this patient?

Body image disturbance

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which possible complication?

Central nervous system deficits

What is the optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment?

Hourly intake and urine output

In patients with extensive burns, what process is responsible for edema occurring in both burned and unburned areas?

Increased capillary permeability

Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for what complication?

Infection

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?

Inhalation injury above the glottis may cause significant edema that obstructs the airway.

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for what complication?

Intraabdominal hypertension

An autograft is used to optimally treat a partial- or full-thickness wound that meets what criteria? SAA

Involves a joint. Involves the face, hands, or feet Requires more than 2 weeks for healing.

Why is silver is used as an ingredient in many burn dressings?

Is effective against a wide spectrum of wound pathogens.

Which complication may manifest after an electrical injury? (Select all that apply.)

Long bone fractures Cardiac dysrhythmias Compartment syndrome of extremities Dark brown urine Acute cataract formation Seizures

A patient admitted with severe burns to the face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to what data noted in the patient's medical history?

Methamphetamine use

during a code, the nurse would perpare to use which iv fluid?

Ns

A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for what possible mental health condition?

PTSD

During cardioversion, the nurse would synchronize the electrical charge to coincide with which wave of the ECG complex?

R

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?

Release of myoglobin from injured tissues

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to accomplish what outcome

Remove excessive wound fluid and promote moist wound healing.

What is the priority nursing intervention for a patient who experienced a chemical burn injury?

Remove the patient's clothes and flush the area with water.

During a code, the nurse would place paddles for anterior defibrillation in what locations?

Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line

The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests?

Serum lactate levels

What is the correct priority order of actions in prehospital primary survey for burn injuries?

Stop the burning process and prevent further injury. Assess ABCs and cervical spine. abirb.com/test Provide oxygen therapy if smoke inhalation is suspected. Make rapid head-to-toe assessment to rule out additional trauma

The nurse is providing care to a patient with burns whose care of plan care includes a prescription for opiates to be given intramuscularly for pain. Why would the nurse contact the primary care provider (PCP) to change the order to intravenous administration?

Tissue edema may interfere with drug absorption of injectable routes.

which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection?

a gunshot wound to the abdomen

which patient has the greatest risk of developing acute respiratory distress syndrome after traumatic injury?

a patient who has recieved large volumes of fluid and/or blood replacemtn

the patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). the nurse perpares which medication that has a short half life and is recommended to treat SVT?

adenosine

which statement best defines the term traumatic injury?

alchol consumption, drug use, or substance contribute to traumatic events

correc order for postop trauma

assess airway, breathing, circ connect pt to monito and mech vent vs, rythm, o2 sat, neuro reassess and evlauate iv lines

a 74 yo pt is admitted to the coronary car eunit with an inferior wall myocardial infractino and developes symptomatic bradycardia with premature ventrcular contractions every third beat. the nurse knows to perpare to administer which medication?

atropine

the patients' monitor shows bradycaria and frequent premature ventricular contractions with a measured blood pressure of 85/50. the nurse anticipates the use of which drug?

atropine 0.5-1 mh iv push

laypersons should use which device to treat lethal ventricular dsyrythmias that occur outside a hospitals setting?

automatic external defibrillator

The nurse chooses which method and concentration of oxygen administration until intubation is established in a patient who has sustained a cardiopulmonary arrest?

bag- valve-mask at fio2 of 100%

which rhythm would be an emergency indication for the application of a transcutaneous pacemaker?

bradycardia with hypotension and syncope

the patient has been admitted to a critical care unit with a diagnosis of acute myocardial infraction. suddenly his monitor alarms and the screen shows a flat line. What action should the nurse take first?

check the patient for unresponsivness

the monitor technician notifies the nurse "stat" that the patient has a rapid, caotic rhythm that looks like V tach. What is the nurses first action?

check the patient immediately

The nurse knows that in advanced cardiac life support, the second survey includes steps A B C D where "D" refers to

differential diagnosis

which statement about mass casulty triage during a disater it true?

disaster victims with the greatest chances fo survival receive priority for treatment

What type of burn is capable of producing either a superficabiairbl.coumta/tensetous injury or a cardiopulmonary arrest and transient but severe central nervous system deficits?

electrical burn

What is the most likely site to have a sheet graft applied?

face

a 24 yo unrestrained driver who sustained multiple tramatic injuries with bp 80/60. what should the survery of this patient upon arrival to the ed?

getting a basline assessment and established priorities

what is the major reason for using a treatment to lower the body temp after cardiac arrest to promote better neurological recovery?

hypothermia decreases the metabolic rate by 7% for each decrease of 1C

in trauma patients, what is the most common cause of symptoms of decreased cardiac output?

hypovolemia

a 90yo nursing home patient is admitted to the critical care unit with a severe case of pneumonia. no living will is noted int he chart. in this event this patient needs intubation and/ or cardiopulmonary resuscitatoin what would the nurse do?

initiate intubation and/ or cardiopulmonary resuscitation efforts

an 18 yo unrestrained passanger with multiple traumas with bp 80/60. What level trauma?

level 1

a patient devlopes frequent ventricular ectopy. the nurse perpares to administer which drug?

lidocaine

during the treatment and managment of the trauma patient, maintaining tissue prefusion, oxygenation, and nutritional support are strategies to prevent what potential comp?

multisystem intravascular coagulation

the nurse is caring for a patient who sustained rib fracture after hitting the steerling wheel. the patient is sponaneously breathing and recieving oxygen via face mask; o2 sat is 95%. o2 drops to 80%, breath sounds absent in left feild. bp went from 126/76 to 84/60. the nurse anticipates what prescription?

needle thoracostomy and chest tube insertion

the patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS complexes are noted on the cariac rhtym strip. To determine if the pacemaker is working the nurse must do which of the follwoing?

palpate the pulse

the nurse admitted a patient to the ed following a fall form the first floor. the patient is 22 yo and smelling of alchol. which intervention would be approperate?

perpare to suction the oropharynx while maintaining cervical spine immobilization

the nurse is having difficulties inserting a large caliber iv cath to faciliate fluid resuscitation to a hypotensive trauma patient. the nurse recommends which of the following emergency procedures to facilliate rapid fluid administration?

placement of an intraosseus catheter

when providing information on trauma prevention, it is important to realize that individuals afe 25-44 yo are likely to experience which type of trauma incident?

posioning forom prescription or illgeal drugs

it is determine that the patient needs a transcutaneous pacemaker until a transvenous pacemaker can be inserted. what is the most approperate nursing intervention?

provide adequate sedation and anlgesics

the patient has PEA. the pcp decides that the cause of the PEA is pericardial tamponade. What is the most approperate treatment for the pericardial tamponade?

resternotomy

whcih is an initial symptom of suspected compartment syndrome?

severe, throbbing pain tin the affected area

the nurse needs to evaluate aterial blood gases before administration of which drug?

sodium bicarboante

which intervention is a strategy to prevent fat embolism syndrome?

stabilize extremity fractures early

a patient is brought to the critical care unit after a motor vehilce crash. on admission, the patient is reporting dyspena and chest pain. upon examination, the nurse notes the lack of breath sounds on the left side and a tracheal shift. what would the most likely diagnosis be?

tension pneumothorax

ROM exercises, early ambulation, and adequate hydration are intervention to prevent this common comp observed in trauma patient?

venous thromboembolism

correct order for preventing hypothermia

warm the ed before pt get there remove wet clothes cover pt with external warming device warm fluids and blood