Test 3: Pancreatitis, Pneumonia, Burns

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured? ________________

27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and the anterior (4.5%) and posterior (4.5%) left arm equals 9%.

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours? _________________

600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the remaining half is given over 16 hours: 4 x 80 x 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

A 56 year old normally healthy patient at the clinic is diagnosed with bacterial community-acquired pneumonia. Before treatment is prescribed, the nurse asks the patient about an allergy to? a. amoxicillin. b. erythromycin. c. sulfonamides. d. cephalosporins.

B. erythromycin

True or False: A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather than with an acidic chemical burn.

False: Alkali burns are harder to treat than acidic chemical burns because the skin will neutralize the acidic burn.

A 45 year old female patient has superficial partial thickness burns on the posterior head and neck, front of the left arm, front and back of the right arm, posterior trunk, front and back of the left leg, and back of right leg. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? a. 22,932 mL b. 26,208 mL c. 16,380 mL d. 12,238 mL

a. 22,932 mL Formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. Pt's weight 91 kg. BSA percentage: 63%... posterior head and neck (4.5%), front of the left arm (4.5%), front and back of the right arm (9%), posterior trunk (18%), front and back of the left leg (18%), back of right leg (9%) equals: 63%......4 x 63 x 91 = 22,932 mL

A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? a. 63% b. 81% c. 72% d. 54%

a. 63% Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? a. 921 mL/hr b. 938 mL/hr c. 158 mL/hr d. 789 mL/hr

a. 921 mL/hr First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 63 kg. BSA percentage: 58.5%...Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742 mL......Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL......Hourly Rate: 7371 divide by 8 equals 921 mL/hr

A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply: a. Acute kidney injury b. Dysrhythmia c. Iceberg effect d. Hypernatremia e. Bone fractures f. Fluid volume overload

a. Acute kidney injury b. Dysrhythmia c. Iceberg effect e. Bone fractures Electric burns are due to an electrical current passing through the body that leads to damage to the skin but also the muscles and bones that are underneath the skin. The patient is at risk for AKI (acute kidney injury) because when the muscles become affected they release myoglobin and the red blood cells release hemoglobin in the blood, which can collect in the kidneys leading to injury. In addition, the heart's electrical system can become damaged leading to dysrhythmia. The iceberg effect can present as well because the extent of damage is not clearly visible on the skin (there can be severe damage underneath). In addition, if the electrical current is strong enough it can lead to bone fractures (specifically cervical spine injuries) due to the severe contraction of the muscles involved.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select all that apply.) a. Age b. Blood pressure c. Respiratory rate d. O2 saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level

a. Age b. Blood pressure c. Respiratory rate e. Presence of confusion f. Blood urea nitrogen (BUN) level Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). The other information is also essential to assess but are not used for CURB-65 scoring

Select-ALL-that-apply: In the pancreas, the acinar cells release: a. Amylase b. Somatostatin c. Lipase d. Protease

a. Amylase c. Lipase d. Protease Acinar cells secrete digestive enzymes into the pancreatic ducts. These enzymes are: Amylase: breaks down carbs to glucose, Protease: breaks down proteins to amino acids, Lipase: breaks down fats

A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurses most appropriate action to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Teach the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.

a. Assist the patient to splint the chest when coughing. Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

a. Auscultate for breath sounds. The patient's statement indicates that pleurisy or a pleural effusion may have developed, and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate for breath sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

a. Auscultate for breath sounds. A patient with facial and chest burns is at risk for inhalation injury and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? (select all that apply) a. Carbonaceous sputum b. Hair singeing on the head and nose c. Lhermitte's Sign d. Bright red lips e. Hoarse voice f. Tachycardia

a. Carbonaceous sputum b. Hair singeing on the head and nose d. Bright red lips e. Hoarse voice f. Tachycardia These are all signs of a possible inhalation injury. Bright red lips and tachycardia are present in carbon monoxide poisoning as well.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.

a. Continue to monitor the urine output. The patients urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patients immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

a. Document the amount of drainage every 8 hours. UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

A patient has full-thickness burns on the front and back of both arm and hands. It is nursing priority to: a. Elevate and extend the extremities b. Elevate and flex the extremities c. Keep extremities below heart level and extended d. Keep extremities level with the heart level and flexed

a. Elevate and extend the extremities This position will decrease edema, which will help prevent compartment syndrome.

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. Elevate head of bed to 30 to 45 degrees. b. Suction the endotracheal tube every 2 to 4 hours. c. Limit the use of positive end-expiratory pressure. d. Give enteral feedings at no more than 10 mL/hr.

a. Elevate head of bed to 30 to 45 degrees. Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patients high energy needs.

What are some patient priorities during the emergent phase of burn management? (select all that apply) a. Fluid volume b. Respiratory status c. Psychosocial d. Wound closure e. Nutrition

a. Fluid volume b. Respiratory status This phase starts from the onset of the burn and ends with the restoration of capillary permeability. Wound closure, and nutrition would be during the acute phase, and would continue into the rehabilitative phase. Psychosocial would be in the rehab phase.

As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for: a. Hemoglobin and myoglobin b. Free iron and white blood cells c. Protein and red blood cells d. Potassium and Urea

a. Hemoglobin and myoglobin Patients who've experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient's urine for these substances.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

a. Increased tactile fremitus Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis? a. Lipase b. Calcium c. Bilirubin d. Potassium

a. Lipase Lipase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Respiratory rate is 24 breaths/min when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

a. O2 saturation is 88%. O2 saturation should improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.

a. Observe for distended neck veins. Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

a. Obtain the O2 saturation. b. Check the patient's pulse rate. d. Notify the health care provider. c. Document the change in status. Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.

A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will provide the best gas exchange? a. On the left side b. On the right side c. In the tripod position d. In the high-Fowler's position

a. On the left side The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions

A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will: a. Place the patient in High Fowler's position. b. Prep the patient for escharotomy. c. Prep the patient for fasciotomy. d. Prep the patient for intubation. e. Place a pillow under the patient's neck. f. Obtain IV access at two sites. g. Restrict fluids.

a. Place the patient in High Fowler's position. b. Prep the patient for escharotomy. d. Prep the patient for intubation. f. Obtain IV access at two sites. After reading this scenario the location of the burns and the patient's presentation should be jumping out at you. The patient is at risk for circumferential burns due to the location of the burns and the depth (full-thickness....will have eschar present that will restrict circulation or here in this example the ability of the patient to breathe in and out). Based on the patient's VS, we see that the respiratory effort is compromised majorly AND that there is a risk of inhalation injury since the patient is coughing up black sooty sputum. Therefore, the nurse should place the patient in high Fowler's position to help with respiratory effort (unless contraindicated with spinal injuries), prep the patient for escharotomy (this will cut the eschar and help relieve pressure and allow for breathing) and prep for intubation to help with the respiratory distress. In addition, obtain IV access in at least two sites for fluid replacement....remember the first 24 hours after a burn a patient is at risk for hypovolemic shock.

An employee spills industrial acid on both arms and legs at work. What action should the occupational health nurse take? a. Remove nonadherent clothing and wristwatch. b. Apply an alkaline solution to the affected area. c. Place a cool compress on the area of exposure. d. Cover the affected area with dry, sterile dressings.

a. Remove nonadherent clothing and wristwatch. With chemical burns, the first action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if the face was exposed). Flush the chemical from the wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution can cause more injury.

While assisting a patient with chronic pancreatitis to the bathroom, you note the patient's stool to be oily/greasy in appearance. In your documentation you note this as: a. Steatorrhea b. Melena c. Currant d. Hematochezia

a. Steatorrhea Steatorrhea is an oily/greasy appearance of the stool which can occur in chronic pancreatitis. This occurs due to the inability of the pancreas to produce digestive enzymes which help break down fats. Fats are not being broken down; therefore, it is being excreted into the stool. Melena is used to describe tarry/black stool, hematochezia is used to describe red stools, and currant are jelly type stools.

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider when a nondiabetic patient's serum glucose is elevated.

a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may need insulin because stress and high-calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2 ) of 85%

a. Weak, nonproductive cough effort The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.

From the pancreas and gallbladder, the common bile duct and pancreatic duct open into the ____________ where digestive enzymes and bile flow into the duodenum via the major duodenal papilla which is surrounded by a muscular valve that controls the release of digestive enzymes known as the ______________. a. ampulla of vater, sphincter of Oddi b. papilla of vater, sphincter of Oddi c. minor duodenal papilla, ampulla of vater d. jejunum, sphincter of pylori

a. ampulla of vater, sphincter of Oddi Digestive enzymes from the pancreas duct and bile from the common bile duct flow through the ampulla of vater (this is where the pancreatic duct and common bile duct form together) into the duodenum via the major duodenal papilla (also called the papilla of vater) which is surrounded by the sphincter of Oddi. This sphincter is a muscular valve that controls the release of digestive enzymes/bile and prevents reflux of stomach contents into the pancreas and bile duct.

You are about to provide care to a patient with severe burns. You will don: a. gloves b. goggles c. gown d. N-95 mask e. surgical mask f. shoe covers g. hair cover

a. gloves b. gown e. surgical mask f. shoe covers g. hair cover Before providing care to a patient with severe burns the nurse would want to wear protective isolation apparel like: gloves, gown, surgical mask, shoe covers, and hair cover. This protects the patient from potential infection.

While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention? a. "He takes medication for glaucoma". b. "I think it has been 10 years or more since he had a tetanus shot." c. "He was told he had COPD last year." d. "He smokes 2 packs of cigarettes a day."

b. "I think it has been 10 years or more since he had a tetanus shot." Patients who have had burns need a tetanus shot if they have not had a vaccine within the past 5 to 10 years.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? a. "I will call my health care provider if I still feel tired after a week." b. "I will continue to do deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I will cancel my follow-up chest x-ray appointment if I feel better next week."

b. "I will continue to do deep breathing and coughing exercises at home." Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

You're providing education to a group of local firefighters about carbon monoxide poisoning. Which statement is correct about the pathophysiology regarding this condition? a. "Patients are most likely to present with cyanosis around the lips and face." b. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body." c. "Carbon monoxide poisoning leads to a hyperoxygenated state, which causes hypercapnia." d. "Carbon monoxide binds to the hemoglobin of the red blood cell and prevents the transport of carbon dioxide out of the blood, which leads to poisoning."

b. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body." This is the only correct statement about carbon monoxide poisoning.

A patient who received treatment for pancreatitis is being discharged home. You're providing diet teaching to the patient. Which statement by the patient requires immediate re-education about the diet restrictions? a. "It will be hard but I will eat a diet low in fat and avoid greasy foods." b. "It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week" c. "I will concentrate on eating complex carbohydrates rather than refined carbohydrates" d. "I will purchase foods that are high in protein"

b. "It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week" A patient with pancreatitis should AVOID any amount of alcohol because of its effects on the pancreas. Remember alcohol is a cause of both acute and chronic pancreatitis. All the other options are correct.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response should the nurse make? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "Why do you feel that way? It will get better as your recovery progresses." d. "It is really too early to know how much your life will be changed by the burn."

b. "It's true that your life may be different. What concerns you the most?" This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate but do not acknowledge the anxiety and depression that the patient is expressing.

A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs: a. Oxygen nasal cannula 5-6 Liters b. 100% oxygen via non-rebreather mask c. Continuous Bipap d. Venturi mask 6 L oxygen

b. 100% oxygen via non-rebreather mask This is the treatment for carbon monoxide poisoning.

You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as: a. 1st Degree (superficial) b. 2nd Degree (partial-thickness) c. 3rd Degree (full-thickness) d. 4th Degree (deep full-thickness)

b. 2nd Degree (partial-thickness) These are the classic characteristics of a 2nd degree (partial-thickness) burn.

A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned? a. 46% b. 37% c. 36% d. 28%

b. 37% Back of right arm (4.5%), posterior trunk (18%), front of left leg (9%), anterior head and neck (4.5%) and perineum (1%) which equals 37%.

A 29 year old male patient has superficial partial thickness burns on the anterior right arm, posterior left leg, and anterior head and neck. The patient weighs 78 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? a. 11,232 mL b. 5,616 mL c. 2,808 mL d. 16,848 mL

b. 5,616 mL Formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. Pt's weight 78 kg. BSA percentage: 18%...Anterior right arm (4.5%), posterior left leg (9%), and anterior head and neck (4.5%) which equals 18%.....4 x 18 x 78 = 5,616 mL

Select the patient below who is at MOST risk for complications following a burn: a. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs. b. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. c. A 36 year old male with full-thickness burns on the front of the left arm. d. A 10 year old with superficial burns on the right leg.

b. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. When thinking about which patient will have the MOST complications following a burn think about: percentage of the total body surface area that is burned (use the rule of nine to calculate), depth of the burn, age, location of the burn, and patient's medical history. The patient in option B has 40.5% TSBA burned (option A 27%, C: 4.5%, D: 9%). Remember that the higher the total of the body surface area that is burned the higher the risk of complications due to an increase in capillary permeability (swelling, hypovolemic shock etc.). In addition, the location of the burn is a major issue with the patient in option B. The burns are on the head and neck and front and back of the torso. Therefore, with head and neck burns always think about respiratory issues because the airway can become compromised due to swelling or an inhalation injury. And with torso burns that are on the front and back, the patient is at risk for circumferential burns that can lead to further respiratory compromise. The other options have burns that are isolated.

21. Which patient should the nurse assess first? a. A patient with burns who reports a level 8 (0 to 10 scale) pain. b. A patient with smoke inhalation who has wheezes and altered mental status. c. A patient with full-thickness leg burns who is scheduled for a dressing change. d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr

b. A patient with smoke inhalation who has wheezes and altered mental status. This patient has evidence of lower airway injury and hypoxemia and should be assessed at once to determine the need for O2 or intubation (or both). The other patients should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management? a. Emergent b. Acute c. Rehabilitative d. Chronic

b. Acute This phase starts when capillary permeability has returned to normal and the patient's vitals are within normal limits and ends with wound closure. The phase after this is rehabilitative.

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.

b. Administer the prescribed morphine. Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis? a. Diabetes b. Alcohol use c. High-protein diet d. Cigarette smoking

b. Alcohol use Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: (select all that apply) a. Place cold compressions on the burn and elevate the right leg below the heart level b. Assess the distal pulses in the right extremity c. Elevate the right leg above the heart level d. Place gauze securely around the leg to prevent infection

b. Assess the distal pulses in the right extremity c. Elevate the right leg above the heart level The patient has burns that completely surround the front and back of the right leg. This can lead to compartment syndrome where the edema from the burn compromises circulation to the distal extremity. The nurse should elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present.

The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes and a weak cough effort. Which action should the nurse take? a. Position the patient on the left side. b. Assist the patient with staged coughing. c. Place a humidifier in the patient's room. d. Schedule a 4-hour rest period for the patient.

b. Assist the patient with staged coughing. The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 4-hour rest period at this time may allow the O2 saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) suppository

b. Blood cultures from two sites Initiating antibiotic therapy rapidly is essential, but it is important to obtain the cultures before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling's Ulcer. What signs and symptoms can present with this condition? a. Swelling and pain on the area distal to the burn b. Burning, gnawing sensation pain in the stomach and vomiting c. Dark red or gray sores on the soles of the feet d. Difficulty swallowing and gagging

b. Burning, gnawing sensation pain in the stomach and vomiting This is a type of ulcer that occurs in the stomach, duodenum, due to a high amount of stress on the body from a burn. The blood supply to the factors that help protect the stomach lining from gastric erosion decreases and this allows for ulcers to form.

A patient with acute pancreatitis is reporting excessive thirst, excessive voiding, and blurred vision. As the nurse, it is priority you? a. Reassure the patient this is normal with pancreatitis b. Check the patient's blood glucose c. Assist the patient with drinking a simple sugar drink like orange juice d. Provide a dark and calm environment

b. Check the patient's blood glucose Patients with acute pancreatitis are at risk for hyperglycemia (the signs and symptoms the patient are reporting are classic symptoms of hyperglycemia). Remember the endocrine function of the pancreas (which is to release insulin/glucagon etc. is insufficient) so the nurse must monitor the patient's blood glucose levels even if the patient is not diabetic.

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax.

b. Continue to monitor the collection device. Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system

A patient admitted with burns over 30% of the body surface 2 days ago now has dramatically increased urine output. Which action should the nurse plan to support maintaining kidney function? a. Monitoring white blood cells (WBCs). b. Continuing to measure the urine output. c. Assessing that blisters and edema have subsided. d. Encouraging the patient to eat adequate calories.

b. Continuing to measure the urine output. The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. WBCs may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. Although adequate nutrition is important for healing, it does not ensure adequate kidney functioning.

Your patient with acute pancreatitis is scheduled for a test that will use a scope to assess the pancreas, bile ducts, and gallbladder. The patient asks you, "What is the name of the test I'm going for later today?" You tell the patient it is called: a. MRCP b. ERCP c. CT scan of the abdomen d. EGD

b. ERCP ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is used to diagnosis and sometimes treat the causes of pancreatitis. It will assess the pancreas, bile ducts, and gallbladder. In addition, the doctor may be able to remove gallstones, dilate the blocked ducts with a stent or balloon, drain presenting cysts etc.

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

b. Elevate the right arm and hand on pillows and extend the fingers. The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow or rolled towel because the head should be kept in an extended position to avoid contractures.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

b. Full-thickness skin destruction With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? a. High fiber, low calories, and low protein b. High calorie, high protein and carbohydrate c. High potassium, high carbohydrate, and low protein d. Low sodium, high protein, and restrict fluids to 1 liter per day

b. High calorie, high protein and carbohydrate This type of diet promotes wound healing and meets the caloric demands of the body.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral nutrition. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day.

b. Insert a feeding tube and initiate enteral nutrition. Enteral nutrition can usually be started during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be given during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients unless the gastrointestinal tract is not available for use.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, Im sorry that Im still alive. My life will never be normal again. Which response by the nurse is best? a. Most people recover after a burn and feel satisfied with their lives. b. Its true that your life may be different. What concerns you the most? c. It is really too early to know how much your life will be changed by the burn. d. Why do you feel that way? You will be able to adapt as your recovery progresses.

b. Its true that your life may be different. What concerns you the most? This response acknowledges the patients feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the patient is expressing.

The nurse is planning care for a patient with acute severe pancreatitis. What is the highest priority patient outcome? a. Having fluid and electrolyte balance b. Maintaining normal respiratory function c. Expressing satisfaction with pain control d. Developing no ongoing pancreatic disease

b. Maintaining normal respiratory function Respiratory failure can occur as a complication of acute pancreatitis and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

What should the nurse teach a patient with chronic pancreatitis is the time to take the prescribed pancrelipase (Viokase)? a. Bedtime b. Mealtime c. When nauseated d. For abdominal pain

b. Mealtime Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

b. Monitor the patient for shortness of breath. The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.

The nurse explains to a patient with an episode of acute pancreatitis that the most effective means of relieving pain by suppressing pancreatic secretions is the use of? a. antibiotics. b. NPO status. c. antispasmodics. d. proton pump inhibitors.

b. NPO status.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased, and no wheezes are audible. What action should the nurse take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

b. Notify the health care provider and prepare for endotracheal intubation. The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified at once so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.

b. Notify the health care provider. The decrease in pulse and numbness in a patient with circumferential burns shows decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess pain level. b. Place on heart monitor. c. Check potassium level. d. Assess oral temperature.

b. Place on heart monitor. After an electrical burn, the patient is at risk for life-threatening dysrhythmias and should be placed on a heart monitor. Assessing the oral temperature and pain is not as important as assessing for dysrhythmias. Checking the potassium level is important, but it will take time before the laboratory results are back. The first intervention is to place the patient on a heart monitor and assess for dysrhythmias so that they can be monitored and treated if necessary.

A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful? a. The patient can move the extremity. b. The right foot's capillary refill is less than 2 seconds. c. The patient reports a new sensation of extreme pain. d. The patient has a positive babinski reflex.

b. The right foot's capillary refill is less than 2 seconds. Escharotomy is performed when a full-thickness burn, due to eschar (which is burned tissue that is hard), is compromising blood flow to the distal extremity. The eschar is cut and this relieves pressure and allows blood to flow to the extremity.

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Insert nasogastric tube for feedings for patients with swallowing problems.

b. Place patients with altered consciousness in side-lying positions. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a sidelying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patients lung sounds several times during the shift b. Placing the patient on droplet precautions and in a private hospital room c. Increasing the oxygen flow rate to keep the oxygen saturation above 90% d. Monitoring patient serology results to identify the specific infecting organism

b. Placing the patient on droplet precautions and in a private hospital room Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate.

Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30 degrees. e. Provide oral care daily with chlorhexidine (0.12%) solution.

b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30 degrees. e. Provide oral care daily with chlorhexidine (0.12%) solution. All these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.

You're assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene? a. The nursing assistant elevates the head of the bed above 30 degrees. b. The nursing assistant places a pillow under the patient's head. c. The nursing assistant places rolled towels under the patient's shoulders. d. The nursing assistant covers the patient with sterile linens.

b. The nursing assistant places a pillow under the patient's head. If a patient has severe burns to the neck (head as well) a pillow should NOT be used under the head because this can cause wound contractions. Instead rolled towels should be placed under the shoulders.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours. c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108.

b. Urine output of 41 mL over past 2 hours. The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 mm Hg systolic and the pulse rate should be less than 120 beats/min. Serous exudate from the burns is expected during the emergent phase.

While the patients full thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70 F (20 C) during dressing changes.

b. Wear gowns, caps, masks, and gloves during all care of the patient. Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85 F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has been having difficulty with body image over the past several months. Which statement by the patient best indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "Do you think dark beige makeup will cover this scar?" d. "I don't think my boyfriend will want to look at me now."

c. "Do you think dark beige makeup will cover this scar?" The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars shows a willingness to discuss appearance but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary shows denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image

A 30 year old female patient has deep partial thickness burns on the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. The patient weighs 150 lbs. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? a. 14,960 mL b. 12,512 mL c. 10,064 mL d. 16,896 mL

c. 10,064 mL Formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. Pt's weight 150 lbs....convert to kg....150 divided by 2.2 = 68 kg. BSA percentage: 37%...Back of right arm (4.5%), posterior trunk (18%), front of left leg (9%), anterior head and neck (4.5%) and perineum (1%) which equals 37%......4 x 37 x 68 = 10,064 mL

A 35 year old male patient has superficial partial-thickness burns to the anterior right arm, posterior left leg, and anterior head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned? a. 36% b. 9% c. 18% d. 29%

c. 18% Anterior right arm (4.5%), posterior left leg (9%), and anterior head and neck (4.5%) which equals 18%.

In reviewing the medical record for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area in the accompanying figure where the nurse will assess for this change. (figure unavailable but location described) a. 1 (Upper Mid Quadrant) b. 2 (Upper Left Quadrant) c. 3 (Umbilicus Mid Quadrant) d. 4 (Lower Mid Quadrant)

c. 3 (Umbilicus Mid Quadrant) The area around the umbilicus should be indicated. Cullen's sign consists of ecchymosis around the umbilicus. Cullen's sign occurs because of seepage of bloody exudates from the inflamed pancreas and indicates severe acute pancreatitis.

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site

c. 400 mL of blood in the collection chamber The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage that is burned? a. 40.5% b. 49.5% c. 58.5% d. 67.5%

c. 58.5% Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%.

A 66 year old female patient has deep partial-thickness burns to both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned? a. 72% b. 63% c. 81% d. 45%

c. 81% Both of the legs on the back (18%), front and back of the trunk (36%), both arms on the front and back (18%), front and back of the head and neck (9%) which equals 81%.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 219 mL/hr b. 625 mL/hr c. 938 mL/hr d. 1875 mL/hr

c. 938 mL/hr Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr

Which patient below is at MOST risk for CHRONIC pancreatitis? a. A 25 year old female with a family history of gallstones b. A 35 year old male who reports social drinking of alcohol c. A 15 year old female with cystic fibrosis d. A 66 year old female with stomach cancer

c. A 15 year old female with cystic fibrosis Patients in options A and B are at slight risk for ACUTE pancreatitis not chronic. Remember the main causes of ACUTE pancreatitis are gallstones and alcohol consumption. In option C, the patient with cystic fibrosis is at MAJOR risk for CHRONIC pancreatitis because they are lacking the protein CFTR which plays a role in the movement of chloride ions to help balance salt and water in the epithelial cells that line the ducts of the pancreas. There is a decreased production of bicarbonate secretion by the epithelial cells. Therefore, this leads to thick mucus in the pancreatic ducts that can lead to blockage of the pancreatic ducts which can cause the digestive enzymes to activate and damage the pancreas. Overtime, the pancreas will experience fibrosis of the pancreas' tissue and will no longer produce digestive enzyme to help with food digestion.

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. A 58-yr-old patient who has compensated cirrhosis and reports anorexia b. A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain c. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) d. A 36-yr-old patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain

c. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101° F (38.3° C)

c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A patient who has twice-daily burn debridements to partial-thickness facial burns. b. A patient who just returned from having a cultured epithelial autograft to the chest. c. A patient who has a 15% weight loss from admission and will need enteral feedings. d. A patient who has blebs under an autograft on the thigh and has an order for bleb aspiration.

c. A patient who has a 15% weight loss from admission and will need enteral feedings. An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients need burn assessment and care that is more appropriate for staff who regularly care for burned patients

Inside the pancreas are special cells that secrete digestive enzymes and hormones. The cells that secrete digestive enzymes are known as ______________ cells. a. Islet of Langerhans b. Protease c. Acinar d. Amylase

c. Acinar Acinar cells secrete digestive enzymes such as amylase, protease, and lipase.

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.

c. Administer prescribed opioids to relieve pain as needed. Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

c. Amylase Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure and heart rate. d. Place the patient in the supine position.

c. Check blood pressure and heart rate. The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate. However, the vital signs may indicate the need for more urgent actions. Because aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurologic status before placing the patient in a supine position

When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.

c. Check the calcium level in the chart. The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

c. Extremity movement All patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are necessary but not as essential as determining the cervical spine status.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction

c. Frequent use of an incentive spirometer Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.

A patient is to undergo skin grafting with the use of cultured epithelial autografts for full-thickness burns. The nurse explains to the patient that this treatment involves? a. Shaving a split-thickness layer of the patient's skin to cover the burn wound. b. Using epidermal growth factor to cultivate cadaver skin for temporary wound coverage. c. Growing small specimens of the patient's skin into sheets to use as permanent skin coverage. d. Exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage.

c. Growing small specimens of the patient's skin into sheets to use as permanent skin coverage.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula

c. Help the patient to splint the chest when coughing. Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.

The _____________ layer of the skin helps regulate our body temperature. a. Epidermis b. Dermis c. Hypodermis d. Fascia

c. Hypodermis This layer contains fatty tissue, veins, arteries, nerves and helps insulate the muscles, bones, organs and helps REGULATE our body temperature.

Your patient with severe burns is due to have a dressing change. You will pre-medicate the patient prior to the dressing change. The patient has standing orders for all the medications below. Which medication is best for this patient? a. IM morphine b. PO morphine c. IV morphine d. Subq morphine

c. IV morphine The best route that is predictable and easily absorbed is via the IV route in burn victims.

After receiving report on a patient receiving treatment for severe burns, you perform your head-to-toe assessment. On arrival to the patient's room you note the room temperature to be 75'F. You will: a. Decrease the temperature by 5-10 degrees to prevent hyperthermia. b. Leave the temperature setting. c. Increase the temperature to a minimum of 85'F. d. Grab warm blankets for the patient.

c. Increase the temperature to a minimum of 85'F. Patients with severe burns can NOT regulate their temperature and are at risk for hypothermia. The room temperature should be a minimum of 85'F.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours b. Continuing to monitor the laboratory results c. Increasing the rate of the ordered IV solution d. Typing and crossmatching for a blood transfusion

c. Increasing the rate of the ordered IV solution The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every hour).

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

c. Medicate the patient with prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Muscle twitching and finger numbness d. Upper abdominal tenderness and guarding

c. Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a. Persistent cough of blood-tinged sputum. b. Scattered crackles in the posterior lung bases. c. Oxygen saturation 90% on 100% O2 by non-rebreather mask. d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics

c. Oxygen saturation 90% on 100% O2 by non-rebreather mask. The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do need continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flowrate.

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a. Report of chest wall pain b. Heart rate of 110 beats/min c. Paradoxical chest movement d. Large bruised area on the chest

c. Paradoxical chest movement Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Place the patient on 100% O2 using a nonrebreather mask. d. Assess for singed nasal hair and dark oral mucous membranes.

c. Place the patient on 100% O2 using a nonrebreather mask. The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting O2 at 100%. The other actions can be taken after the action to correct gas exchange

Which action should the nurse take to prepare a patient with a pleural effusion for a thoracentesis? a. Remind the patient not to eat or drink 6 hours. b. Start a peripheral IV line to administer sedation. c. Position the patient sitting up on the side of the bed. d. Obtain a collection device to hold 3 liters of pleural fluid.

c. Position the patient sitting up on the side of the bed. When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema

A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient's plan of care, which nursing diagnosis is priority at this time? a. Impaired skin integrity b. Risk for fluid volume overload c. Risk for infection d. Ineffective coping

c. Risk for infection The patient is now in the acute phase where fluid resuscitation was successful and ends with wound closure. Therefore, during this stage diuresis occurs (so fluid volume deficient could occur NOT overload) and INFECTION. The location of the burns increases the risk of infection because these areas naturally harbor bacteria. Therefore, this takes priority because during this phase wound healing is promoted.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit of 53% b. Serum sodium of 147 mEq/L c. Serum potassium of 6.1 mEq/L d. Blood urea nitrogen of 37 mg/dL

c. Serum potassium of 6.1 mEq/L Hyperkalemia can lead to life-threatening dysrhythmias. The patient needs cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Inspect the contact burns. b. Check the blood pressure. c. Stabilize the cervical spine. d. Assess alertness and orientation.

c. Stabilize the cervical spine. Cervical spine injuries are often associated with electrical burns. Therefore, stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

Esomeprazole is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug? a. Bowel sounds b. Stool frequency c. Stool occult blood d. Abdominal distention

c. Stool occult blood H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has sustained burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite.

When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse? a. Serum K+ of 4.5 mEq/L b. Urine output of 35 mL/hr c. Decreased bowel sounds d. Blood pressure of 86/72 mm Hg

d. Blood pressure of 86/72 mm Hg

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 6000/µL. d. Increased tactile fremitus is palpable over the right chest.

c. The patient's white blood cell (WBC) count is 6000/µL. The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first? a. Give the prescribed PRN sedative drug. b. Offer reassurance and reorient the patient. c. Use pulse oximetry to check the oxygen saturation. d. Notify the health care provider about the patient's status.

c. Use pulse oximetry to check the oxygen saturation. Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel

c. Vanilla milkshake A patient with a burn injury needs high-protein and high-calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice but low in protein. Bananas are a good source of potassium but are not high in protein and calories.

Which nursing action prevents cross contamination when the patient's full-thickness burn wounds to the face are exposed? a. Using sterile gloves when removing dressings. b. Keeping the room temperature at 70° F (20° C). c. Wearing gown, cap, mask, and gloves during care. d. Giving IV antibiotics to prevent bacterial colonization.

c. Wearing gown, cap, mask, and gloves during care. Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? a. "Blood loss from burned tissue is the most likely cause of hypovolemia." b. "Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." c. "The usual cause of hypovolemia is evaporation of fluid from denuded body surfaces." d. "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

d. "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

A 35 year old male patient has full thickness burns to the anterior and posterior head and neck, front of left leg, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned? a. 37% b. 14.5% c. 29% d. 19%

d. 19% Anterior and posterior head and neck (9%), front of left leg (9%), perineum (1%) which equals 19%.

A 59 year old male patient has full thickness burns on both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. The patient weighs 186 lbs. Use the Parkland Burn Formula: You've already infused fluids during the first 8 hours. Now what will you set the flow rate during the next 16 hours (mL/hr) based on the total you calculated? a. 563 mL/hr b. 854 mL/hr c. 289 mL/hr d. 861 mL/hr

d. 861 mL/hr First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 186 lbs...need to convert to kg: 186 divided by 2.2 = 85 kg. BSA percentage: 81%...Both of the legs on the back (18%), front and back of the trunk (36%), both arms on the front and back (18%), front and back of the head and neck (9%) which equals 81%.......4 x 81 x 85 = 27,540 mL. You've already infused half of the solution during the first 8 hours...so 13,770 mL is left and it needs to be infused over 16 hours. Hourly rate: 13,770 mL divided by 16 hours equals 861 mL/hr

A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to: a. Prevent hypothermia b. Assess the blood pressure c. Assess the airway d. Prevent infection

d. Assess the airway Due to the location of the burns (face and neck), the patient is at major risk for respiratory issues due to damage to the upper airways and the risk of an inhalation injury.

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

d. Abdominal pain is decreased. NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

During a home health visit, you are assessing how a patient takes the prescribed pancreatic enzyme. The patient is unable to swallow the capsule whole, so they open the capsule and mix the beads inside the capsule with food/drink. Which food or drink is safe for the patient to mix the beads with? a. Pudding b. Ice cream c. Milk d. Applesauce

d. Applesauce The patient should mix the medications with acidic foods like applesauce. It is very important the patient does NOT use alkaline foods for mixing (like dairy products, pudding etc.) because they can damaged the enzyme.

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

d. Apply water-based cream to burned areas frequently. Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury

During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of? a. Blood loss from injured tissue. b. Third spacing of fluid into fluid-filled vesicles. c. Evaporation of fluid from denuded body surfaces. d. Capillary permeability with fluid shift to the interstitium.

d. Capillary permeability with fluid shift to the interstitium.

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction

d. Chest tube connected to suction The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.

A patient is admitted to the ER with the following signs and symptoms: very painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the belly button. As the nurse, you know this is called? a. Grey-Turner's Sign b. McBurney's Sign c. Homan's Sign d. Cullen's Sign

d. Cullen's Sign This is known as Cullen's Sign. It represents retroperitoneal bleeding from the leakage of digestive enzymes from the inflamed pancreas into the surrounding tissues which is causing bleeding and it is leaking down to umbilicus tissue. Remember the C in Cullen for "circle" and the belly button forms a circle. The patient can also have Grey-Turner's Sign which is a bluish discoloration at the flanks (side of the abdomen). Remember this by TURNER ("turn her" over on her side) which is where the bluish discoloration will be.

You're caring for a 45 year old patient who is admitted with suspected acute pancreatitis. The patient reports having extreme mid-epigastric pain that radiates to the back. The patient states the pain started last night after eating fast food. As the nurse, you know the two most common causes of acute pancreatitis are: a. High cholesterol and alcohol abuse b. History of diabetes and smoking c. Pancreatic cancer and obesity d. Gallstones and alcohol abuse

d. Gallstones and alcohol abuse Main causes of acute pancreatitis are gallstones and alcohol consumption. Heavy, long-term alcohol abuse is the main cause of CHRONIC pancreatitis.

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Give IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

d. Give IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze. c. Apply silver sulfadiazine cream. a. Apply sterile gauze dressing. b. Document wound appearance. Because partial-thickness burns are very painful, the nurse's first action should be to give pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)

d. Hydromorphone (Dilaudid) Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. I am going to buy a rib binder to wear during the day. b. I can take shallow breaths to prevent my chest from hurting. c. I should plan on taking the pain pills only at bedtime so I can sleep. d. I will use the incentive spirometer every hour or two during the day.

d. I will use the incentive spirometer every hour or two during the day. Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem should the nurse assign as the priority? a. Fatigue b. Hyperthermia c. Impaired mobility d. Impaired gas exchange

d. Impaired gas exchange All these problems are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

d. Insertion of a chest tube with a chest drainage system The patients history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patients clinical manifestations are not consistent with these problems.

The nurse is caring for a patient with pneumonia. If a pleural effusion is developing, the nurse would expect which finding? a. Barrel-shaped chest b. Paradoxical respirations c. Hyperresonance on percussion d. Localized decreased breath sounds

d. Localized decreased breath sounds

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

d. Piperacillin/tazobactam (Zosyn) Early initiation of antibiotic therapy has been shown to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy

During the emergent phase of burn management, you would expect the following lab values: a. Low sodium, low potassium, high glucose, low hematocrit b. High sodium, low potassium, low glucose, high hematocrit c. High sodium, high potassium, high glucose, low hematocrit d. Low sodium, high potassium, high glucose, high hematocrit

d. Low sodium, high potassium, high glucose, high hematocrit Think about the increase in the capillary permeability that happens with severe burns, which causes the plasma to leave the intravascular system and enter the interstitial tissue: Low sodium..why: sodium leaves with the plasma to the interstitial tissue and drops the levels in the blood; High potassium...why? damaged cells lysis and leak potassium which increases the leave in the blood; high glucose...why? stress response leads the liver to release glycogen and this increases levels; high hematocrit...why? when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases (this will decrease when the patient's fluid is replaced).

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next? a. Increase the tidal volume and respiratory rate. b. Increase the fraction of inspired oxygen (FIO2 ). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).

d. Lower the positive end-expiratory pressure (PEEP). Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax.

During the emergent phase of burn care, which assessment is most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

d. Measure hourly urine output. When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to: a. Increase the IV fluids b. Continue to monitor the patient c. Decrease the IV fluids d. Notify the physician of this finding

d. Notify the physician of this finding The patient's urinary output is too low and needs more fluids. It should be at least 30 mL/hr. Therefore, the nurse must notify the physician for further orders. The nurse can NOT increase or decrease IV fluids without a physician's order.

Which assessment finding is of most concern for a patient with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

d. Palpable abdominal mass A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

The physician orders a patient with pancreatitis to take a pancreatic enzyme. What assessment finding demonstrates the pancreatic enzymes are working properly? a. Abdominal girth is decreased b. Skin turgor is less than 2 seconds c. Blood glucose is 250 d. Stools appear formed and solid

d. Stools appear formed and solid Pancreatic enzymes help the body break down carbs, proteins, and fats because the body is not sufficiently producing digestive enzymes anymore. Hence, the stool will not appear as oily or greasy (decrease in steatorrhea) but appear solid and formed.

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound

d. Tape a nonporous dressing on three sides over the wound The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

The nurse supervises unlicensed assistive personnel (UAP) providing care for a patient who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene? a. UAP assists the patient to ambulate to the bathroom. b. UAP helps splint the patient's chest during coughing. c. UAP transfers the patient to a bedside chair for meals. d. UAP lowers the head of the patient's bed to 15 degrees.

d. UAP lowers the head of the patient's bed to 15 degrees. Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation.

d. Use pulse oximetry to check oxygen saturation. Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient

Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)

d. hydromorphone (Dilaudid) Opioid pain medications are the best choice for pain control. The other drugs are used as adjuvants to enhance the effects of opioids.