Adult Health II Exam 2 Chapter 21, 26, 28 Book Questions
Estimate the total body surface area burn injury using the rule of 9's. Burns involve the entire right arm and upper back. _____%
18%
A patient is hospitalized with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. The respiratory therapist applied a non-rebreather mask. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Respiratory rate is 6/min. Oxygen saturation decreases to 88%. The patient is unresponsive. What is the priority nursing intervention? a. Notify the HCP and get ready for intubation. b. Encourage the patient to cough and auscultate the lungs again. c. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. d. Document the findings and continue to monitor the patient's breathing.
A
Which lab result supports the need for additional IV fluid to treat burn shock? a. Hematocrit 52% b. Sodium 137 mEq/L c. WBC 12.5 × 109/L d. Potassium 3.4 mmol/L
A
A patient with multiple gunshot wounds returns to the ICU from surgery. Vital signs are stable. They are making no spontaneous respiratory effort. Which mode of ventilation would be most appropriate? a. Assist control (AC) b. Pressure support (PS) c. Bi-level positive airway pressure (Bi-PAP) d. Synchronized intermittent mandatory ventilation (SIMV)
A
An older man arrives in triage disoriented and dyspneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to a. assess his vital signs. b. obtain a brief medical history from his wife. c. start supplemental O2 and have the provider see him. d. determine the kind of insurance he has before treating him.
A
In a spontaneously breathing patient, the nurse notes tidaling of the water level in the water-seal chamber of the chest tube drainage system. The nurse would a. continue to monitor the patient. b. check all connections for a leak in the system. c. raise the collection unit above the level of the heart. d. clamp the tubing at a distal point away from the patient.
A
What intervention prevents hypertrophic scarring during the rehabilitation phase of burn recovery? a. Applying pressure garments b. Repositioning the patient every 2 hours c. Performing active ROM at least every 4 hours d. Applying a water-based moisturizer to healed skin
A
What nutrition intervention may promote wound healing for a patient with a 10% burn injury? a. Eat a high-protein, high-carbohydrate diet b. Increase normal caloric intake by about 4 times c. Eat at least 1500 calories/day in small, frequent meals d. Eat a lactose-free diet to reduce the potential for diarrhea
A
Which assessment finding concerns you most in a patient with pneumonia who is receiving noninvasive ventilation (Bi-PAP)? a. New onset of confusion to time and place b. Fine crackles on auscultation of affected lobe c. Patient asks to remove the mask for oral care d. HR: 98, RR: 16 bpm, BP: 110/60, SpO2: 93%
A
Which nursing action would be the highest priority when suctioning a patient with an oral ET tube or tracheostomy? a. Hyperoxygenate with 100% FIO2 before suctioning. b. Auscultate lung sounds after suctioning is completed. c. Instill 5 mL of normal saline into the tube before suctioning. d. Give antianxiety medications 30 minutes before suctioning.
A
Which technique would be most appropriate for a patient with mild COPD to promote airway clearance? a. Huff coughing b. Postural drainage c. Pursed lip breathing d. High-frequency chest wall oscillation
A
Which findings indicate the patient is ready for weaning from mechanical ventilation? (select all that apply) a. Serum hemoglobin of 15 g/dL b. Respirations of 18 breaths/min c. Patient is alert and follow commands d. Chest x-ray shows large pleural effusion e. Mean arterial pressure (MAP) of 55 mm Hg f. ABGS: pH 7.38, PaCO2 37 mm Hg, 24 mEq/L, PaO2 94
A, B, C, F
What nursing interventions can be used to manage burn pain? (select all that apply) a. Suggest pain management options. b. Use a pain-rating tool to monitor the patient's level of pain. c. Delay painful dressing changes until the patient's pain is completely relieved. d. Use a multimodal approach (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. Provide nonpharmacologic therapies (e.g., music therapy, distraction) to replace opioids in the acute phase of a burn injury.
A, B, D
What interventions does the nurse anticipate for a patient with an aspirin overdose? (select all that apply.) a. Hemodialysis b. Corticosteroids c. Hyperbaric O2 d. Gastric lavage e. Activated charcoal
A, D, E
A chemical explosion occurs at a nearby industrial site. First responders report that victims are decontaminated at the scene, and about 125 workers will need medical evaluation and care. The first action of the nurse receiving this report should be to a. issue a code blue alert. b. activate the hospital's emergency response plan. c. notify the Federal Emergency Management Agency (FEMA). d. arrange for the American Red Cross to provide aid to victims.
B
A patient has a core temperature of 90°F (32.2°C). The most appropriate rewarming technique would be a. passive rewarming with warm blankets. b. active internal rewarming using warmed IV fluids. c. passive rewarming using air-filled warming blankets. d. active external rewarming by submersing in a warm bath.
B
After a left lower lobe lobectomy, an appropriate nursing measure is to a. position the patient prone every 2 hours. b. monitor the chest tube drainage and functioning. c. auscultate lung sounds frequently in the lower left lobe. d. administer IV fluid boluses to maintain blood pressure.
B
Which wound description indicates a need for excision and grafting? (select all that apply) a. Red, painful blisters b. Leathery, brown, exposed tendon c. Pearly white color, insensitive to pain, dry d. Charred eschar, visible thrombosed blood vessels e. Large, fluid-filled vesicles, moderate edema, moist, red
B
Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy would include (select all that apply) a. encouraging regular exercise such as swimming. b. washing around the stoma daily with a moist washcloth. c. emphasizing the importance of regular follow-up appointments d. providing pictures and "hands-on" instruction for tracheostomy care. e. having a list of emergency contact numbers and where to obtain supplies.
B, C, D, E
An older woman arrives in the ED reporting severe pain in her right shoulder. The nurse notes her clothes are soiled with urine and feces. She tells the nurse that she lives with her son and that she "fell." She is tearful and asks you if she can be admitted. What possibility should the nurse consider? a. Dementia b. Possible cancer c. Family violence d. Orthostatic hypotension
C
Nursing management of a patient with an oral ET tube would include a. maintaining ET tube cuff pressure at 35 to 40 cm H2O. b. routine suctioning of the ET tube at least every 2 hours. c. observing the patient for spontaneous respiratory effort and work of breathing. d. preventing ET tube dislodgment by limiting mouth care to lubrication of the lips.
C
The major advantage of a Venturi mask is that it can a. deliver up to 80% O2. b. provide continuous 100% humidity. c. deliver a precise concentration of O2. d. be used while a patient eats and sleeps.
C
The nurse monitors the patient with positive pressure mechanical ventilation for a. paralytic ileus because pressure on the abdominal contents affects bowel motility. b. diuresis and sodium depletion because of increased release of atrial natriuretic peptide. c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return. d. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels.
C
Which instruction would the nurse provide to prevent burn injuries? a. Set hot water temperature at 140°F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Do not allow older adults to cook unattended.
C
A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. What is the most important nursing intervention following surgery? a. Wash the wound with soap and water 3 times a day. b. Medicate for pain relief in between dressing changes. c. Reapply a new dressing without disturbing the wound bed. d. Assess the wound for signs of infection during dressing changes.
D
A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care team is planning for discharge. The first action the nurse would take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. give the patient written information and websites resources for burn survivors. c. teach the patient and the caregiver proper wound care to be performed at home. d. review the patient's current health care status and readiness for discharge to home.
D
Immediate care priorities in the first few hours for a patient with a new tracheostomy include a. encouraging early mobility. b. changing the tracheostomy ties. c. suctioning the tracheostomy hourly. d. observing for bleeding at the insertion site.
D
