AH3 Final Practice Questions
Infant weighs 6 kg. Ranitidine syrup 3 mg/kg/day in two divided doses. The med on hand is 15 mg/ml. How many ml should the nurse administer for each dose?
0.6 ml.
A pt as a prescription for dopamine to be infused via central line at 5 mcg/kg/min. The pt weighs 200 Ibs. The med available is 400 mg per 500 ml D5W. The nurse should administer how many ml/hr?
34 ml.
35% TBSA burned. 187 Ibs. How much IV fluid should the nurse administer within the first 4 hrs of admission?
6, 120. 85 kg x 4 x 36 = 12,240 /2 = 6,120.
A patient has the following mixed deep partial-thickness and full-thickness burn injuries: face, anterior neck, R anterior trunk, and anterior surfaces of the R arm and lower leg. What is the extent of their burns? Is it possible to determine the actual extent and depth of a burn in the emergent phase?
22.5% TBSA. No, because edema and inflammation obscure the demarcation of zones of injury.
A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
24 mL/hr
A nurse is preparing to administer 1,000 mL of lactated Ringer's IV over 6 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
28 gtt/min
A nurse is caring for a client who is postoperative hip arthroplasty and has a new prescription for enoxaparin 1 mg/kg/dose subcutaneous every 12 hr. The client weighs 95 lbs. How many mg should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
43.2 mg
5,000 U bolus of Heparin followed by an IV drip at 1,000 U/hr. A premixed bag of 25,000 U in 250 ml of D5W is available. The nurse should se the infusion to how many ml for the bolus?
50 ml.
A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)? A. 9 percent B. 18 percent C. 36 percent D. 54 percent
54% Each arm represents 9% of the client's TBSA and each leg represents 18% of the client's TBSA totaling 54%.
After the nurse receives the change-of-shift report at 7:00 am, which client must the nurse assess first? A. A 23-year-old client with a migraine headache who reports severe nausea associated with retching B. A 45-year-old client who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching C. A 59-year-old client with Parkinson disease who will need a swallowing assessment before breakfast D. A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain
63 year old with MS. Urinary tract infections (UTIs) are a frequent complication in clients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these clients. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The health care provider should be notified immediately so that IV antibiotic therapy can be started quickly. The other clients should be assessed as soon as possible, but their needs are not as urgent as those of this client.
A nurse is preparing to administer cefazolin IVPB over 20 min. Available is cefazolin 1 g in 100 mL of dextrose 5% in water (D5W). The drop factor of the manual IV tubing is 15gtt/mL. The nurse should set the IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
75 gtt/min
A nurse is preparing to administer total parental nutrition (TPN) 1800 mL to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
75 mL/hr
The nurse is monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? A. Client admitted with heart failure who has atrial fib with a rate of 88 beats/min while at rest B. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min C. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions D. Client who recently started taking atenolol and has a first-degree heart block, with a rate of 58 beats/min
Acute MI. Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other clients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of myocardial infarction.
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus
Airway obstruction When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction. B. Infection. C. Fluid imbalance. D. Paralytic Ileus.
Airway obstruction. When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.
In late refractory shock, a pt with massive thermal burns, what should the nurse expect the pt's labs to reveal? A. Resp alkalosis. B. Decreased K. C. Increased blood glucose. D. Increased ammonia levels.
Ammonia. In late refractory shock, progressive cellular destruction causes changes in labs that indicate organ damage. Increasing ammonia indicates impaired liver function.
During the initial postoperative assessment of a client who has just been transferred to the post-anesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the most immediate implications for the client's care? A. Arterial line indicates a blood pressure of 190/112 mm Hg. B. Cardiac monitor shows frequent premature atrial contractions. C. There is no response to verbal stimulation D. Urine output is 40 ml of amber urine.
Arterial line. Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the client's hemodynamic stability.
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first? A. Prepare the client for reintubation. B. Assess the client's airway. C. Suction the client's mouth. D. Elevate the client's head of bed.
Assess the airway. The first action the nurse should take using the nursing process is to assess the client's airway for obstruction, listen to the client's lungs for air movement, and provide mechanical ventilation with a bag-valve-mask device to reduce the risk for hypoxia.
A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? A. Assess the client's level of consciousness. B. Administer epinephrine. C. Auscultate for wheezing. D. Monitor for hypotension.
Auscultate for wheezing. When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.
What is the priority nursing responsibility in preventing shock? A. Frequently monitor VS. B. using aseptic technique for all invasive procedures. C. Being aware of the potential for shock in all pts at risk. D. teaching pts health promotion activities to prevent shock.
Being aware of the potential. Prevention necessitates identification of person who are at risk and a thorough baseline nursing assm with frequent ongoing assm to monitor and detect changes in pts at risk. Frequent monitoring of VS is not necessary. Aseptic technique for all invasive procedures should be implemented but will not always prevent all types of shock.
A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? A. Kernig's sign B. Nuchal rigidity C. Brudzinski's sign D. Bradykinesia
Brudzinskis. This client is manifesting a positive Brudzinski's sign, which is indicated when the hips and knees flex when neck is flexed. A positive Brudzinski's sign is a common sign of meningitis.
The nurse determines that a large amount of crystalloid fluids administered to a pt in septic shock is effective when monitoring reveals what? A. CO 2.6. B. CVP 15. C. PAWP 4. D. HR 106.
CVP 15. The endpoint of fluid resuscitation in septic and hypovolemic shock is CVP of 15 or PAWP of 10-12. This CO is too low and HR is too high to indicate adequate fluid replacement.
What is the initial cause of hypovolemia during the emergent phase of burn injury? A. Increased capillary permeability. B. Loss of Na in the interstitium. C. Decreased vascular oncotic pressure. D. Fluid loss from denuded skin surfaces.
Cap permeability. The most pronounced effect is caused by fluid shifts out of the blood vessels as a result of permeabiliy.
Which hemodynamic monitoring description of the identified shock is accurate? A. Tachycardia with HTN is neurogenic shock. B. Increased PAWP and decreased CO are cardiogenic shock. C. Anaphylactic shock is increased SVR, decreased CO and decreased PAWP. D. In septic shock, bacterial endotoxins cause vascular changes that result in increased SVR, decreased CO and increased HR.
Cardiogenic shock. Neurogenic shock are bradycardia and hypoTN. Hypovolemic shock has increased SVR, decreased CO, decreased PAWP. Septic shock has decreased SVR and increased CO.
The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6°F (39.2°C) orally. Which prescribed intervention should be implemented first? A. Administer codeine 15 mg orally for the client's headache. B. Infuse ceftriaxone 2g IV to treat the infection. C. Give acetaminophen 650 mg orally to reduce the fever D. Give furosemide 40 mg IV to decrease intracranial pressure.
Ceftriaxone. Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible but are not as important as starting antibiotic therapy.
The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? A. The client's condition is improving B. The client's condition is deteriorating C. The client will need intubation and mechanical ventilation D. The client's medication regime will need adjustment
Condition is deteriorating. The GCS is used in many acute care settings to establish baseline data in these areas: eye opening, motor response, and verbal response. The client is assigned a numeric score for each of these areas. The lower the score, the lower the client's neurologic function. A decrease of 2 or more points in the Glasgow Coma Scale score total is clinically significant and should be communicated to the health care provider immediately.
What should the nurse assess the pt for during the administration of IV norepinephrine (Levophed)? A. HypoTN. B. marked diuresis. C. Met alkalosis. D. Decreased tissue perfusion.
Decreased tissue perfusion. As a vasopressor, levophed may cause severe vasoconstriction, which would further decrease tissue perfusion, especially if fluid replacement is inadequate. Vasopressors generally cause HTN, reflex bradycardia, decreased UO.
The nurse is caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding takes priority? A. Deviated trachea. B. Unequal pupils. C. Ecchymosis in the flank. D. Irregular apical pulse.
Deviated trachea. A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not corrected. All of the other symptoms are potentially serious but are of lower priority.
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. Urinary output 25 mL/hr B. Difficulty swallowing C. Heart rate 122/min D. Pain of 6 on a scale of 0 to 10
Difficulty swallowing. Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is difficulty swallowing as this is can be an indication that the client's airway is obstructed.
Which intervention may prevent GI bacterial and endotoxin translocation in a pt with SIRS? A. Early enteral feedings. B. Surgical removal of necrotic tissue. C. Aggressive multiple abx therapy. D. Strict aseptic technique in all procedures.
Early enteral feedings. This increases blood supply to the GI tract. Known infections are tx with specific agents and broad spectrum agents are used only until the agent is identified.
What type of burn injury would cause myoglobinuria, long bone fractures, and dysrhythmias/cardiac arrest? A. Thermal. B. Electrical. C. Chemical. D. Smoke/ Inhalation.
Electrical. This causes tissue damage from intense heat generated by an electrical current passing through the tissues, that can fracture long bones and vertebrae. Myoglobin is released when massive muscle damage occurs. The risk of dysrhythmias is present for 24 hrs.
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Observe client's respiratory status. B. Elevate the head of the client's bed 30° to 45°. C. Monitor intake and output every 8 hr. D. Check residual volume every 4 to 6 hr.
Elevate HOB to 30-45. A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote gastric emptying and reduce the risk of aspiration.
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? A. Teach controlled coughing and deep breathing. B. Provide a brightly lit environment. C. Elevate the head of the bed 20°. D. Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.
Elevate HOB. The nurse should elevate the head of the bed less than 25° to promote reduction of intracranial pressure.
Which pt manifestations confirm the development of MODS? A. Upper GI bleed, GCS 7, Hct 25%. B. elevated bili, creatinine 3.8, platelets 15,000. C. UO 30 ml/hr, BUN 45, WBCs 1120. D. RR 45, PaCO2 60, CXR with bilateral diffuse patchy infiltrates.
Elevated bili, creatinine, platelets. MODS is confirmed when there is defined clinical evidence of failure of 2+ organs. Elevated bili indicates liver dysfunction, creatinine of 3.8 indicates kidney injury, and platelets of 15,000 indicate hematologic failure.
The patient was admitted to the burn center with a full-thickness burn 42 hrs after the thermal burn occurred. The nurse will apply actions r/t which phase of burn management? A. Acute. B. Emergent. C. Postacute. D. Rehabilitative.
Emergent. This lasts up to 72 hrs after the injury and focuses on fluid resuscitation. The acute phase is after the emergent and may last weeks - months but begins when extracellular fluid is mobilized and diuresis begins. There is no postacute phase. The rehab phase begins weeks - months after the injury, when the wounds have healed and the pt participates in self-care.
Which statement is accurate? A. MODS may occur independently from SIRS. B. All pts with septic shock develop MODS. C. The GI system is often the first to show evidence of SIRS and MODS. D. A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin.
Endotoxin. A common initial mediatory that causes endothelial damage leading to SIRS or MODS is endotoxin. MODS results from SIRS. Not all pts with septic shock develop MODS, although they do have SIRS. The resp system is frequently the first to show evidence of SIRS and MODS.
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? A. Dobutamine. B. Methylprednisolone. C. Furosemide. D. Epinephrine.
Epinephrine. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer epinephrine, a bronchodilator and vasopressor used for allergic reactions to reverse severe manifestations of anaphylactic shock.
A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? A. Trochanter roll B. Sheepskin heel pad C. Abduction pillow D. Footboard
Footboard. Plantar flexion contractures, or foot drop, develop when a client's unsupported feet are constantly in plantar flexion. The nurse should place the soles of the client's feet against a footboard, a flat wooden or plastic panel perpendicular to the bed, to keep them dorsiflexed and, therefore, prevent foot drop.
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first? A. Evaluate the client's neurological status. B. Perform a complete blood count. C. Check the client's temperature. D. Administer an oral analgesic
Eval neuro status. Manifestations of a headache and stiff neck (nuchal rigidity) are indications that the client might have meningitis. The greatest risk to the client is injury from increased intracranial pressure, which can lead to brain herniation and death. Therefore, the nurse should complete a neurological assessment as a baseline. If the client does have meningitis, neurological checks should be completed every 2 to 4 hr.
A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) A. Headache B. Neck pain and stiffness C. Slurred speech D. Pupillary changes E. Disorientation
Headache, slurred speech, pupillary changes, disorientation. Headache is correct. A client who has increasing ICP might manifest a headache. Neck pain and stiffness is incorrect. Neck pain and stiffness are not manifestations of increasing ICP. Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. Disorientation is correct. A client who has increasing ICP might display disorientation or confusion.
It is the summer season, and clients with signs and symptoms of heat-related illness come to the emergency department. Which client needs attention first? A. Older adult reports dizziness and syncope after standing in the sun for several hours to view a parade. B. Marathon runner reports severe leg cramps and nausea. C. Healthy homemaker reports that air conditioner has been broken for a few days. She has tachypnea, hypotension, fatigue, and profuse diaphoresis. D. Homeless person displays altered mental status, poor muscle coordination, and hot, dry ashen skin, duration of heat exposure unknown.
Homeless person. The homeless person has symptoms of heat stroke, a medical emergency that increases the risk for brain damage. The older adult client is at risk for heat syncope and should be educated to rest in a cool area and avoid future similar situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes administration of fluids (IV or oral) and cooling measures.
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make? A. Fluid overload B. Left ventricular failure C. Intracardiac shunt D. Hypovolemia
Hypovolemia. A low CVP indicates reduced right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuresis.
A pt with deep partial-thickness burns over 45% of their trunk and legs is going for debridement 48 hrs post-burn. What is the drug of choice? A. IV morphine. B. Midazolam. C. IM meperidine (Demerol). D. Long-acting PO morphine.
IV morphine. This is the drug of choice for pain control, and should not be given IM. Amnesia from Midazolam is not needed for pain control.
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? A. Impaired tissue perfusion B. Alteration in body image C. Alteration in activity tolerance D. Impaired skin integrity
Impaired tissue perfusion. When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.
A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading. B. Inability to recognize family members. C. Right hemiparesis. D. Aphasia.
Inability to recognize family members. The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? A. "Incorporate nonverbal cues in the conversation." B. "Ask multiple choice questions as part of the conversation." C. "Use a higher-pitched tone of voice when speaking." D. "Use simple, child-like statements when speaking."
Incorporate nonverbal cues in the conversation. Nonverbal cues enhance the client's ability to comprehend and use language.
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A. Decrease in the respiratory rate from 20 to 16/min. B. Decrease in the urinary output from 50 mL to 30 mL per hour. C. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F) D. Increase in the heart rate from 88 to 110/min.
Increase in the heart rate from 88 to 110/min. Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the heart rate increases steadily. In the first stage of shock (compensatory), the heart rate is > 100/min. As shock progresses, the heart rate continues to accelerate to more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes very erratic and may develop asystole.
What abnormal finding would the nurse expect to find in early compensatory shock? A. Met acidosis. B. Increased serum Na. C. Decreased blood glucose. D. Increased serum K.
Increased Na. Activation of the RAAS stimulates the release of aldosterone, which causes Na reabsorption and K excretion by the kidney, elevating serum Na levels and decreasing serum K levels.
During the early emergent phase of burns, the pt's labs would be: A. increased hct, decreased albumin, decreased Na, increased K. B. decreased hct, albumin, Na, K. C. decreased hct, increased albumin, Na, K. D. increased hct, albumin, decreased Na and K.
Increased hct, decreased albumin, decreased Na, increased K. Increased capillary permeability, water, Na, and plasma proteins move into the interstitial spaces, decreasing Na and albumin. K is elevated d/t injured cells and hemolyzed RBCs. An elevated hct is caused by water loss into the interstititum, increasing hemoconcentration.
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? A. Insert an indwelling urinary catheter. B. Inspect the mouth for signs of inhalation injuries. C. Administer intravenous pain medication. D. Draw blood for a complete blood cell (CBC) count.
Inspect the mouth for signs of inhalation injuries. Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time.
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? A. Insert an indwelling urinary catheter. B. Inspect the mouth for signs of inhalation injuries. C. Administer intravenous pain medication. D. Draw blood for a complete blood cell (CBC) count.
Inspect the mouth. Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time.
The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? A. Instructing the client to sit up straight and the client responds with a puzzled expression B. Moving the client's food tray to the right side of his over-bed table C. Assisting the client with passive range-of-motion (ROM) exercises D. Combing the hair on the left side of the client's head when the client always combs his hair on the right side
Instructing the client to sit up straight and the client responds with a puzzled expression. Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse needs to remind the student of this phenomenon and discuss the appropriate interventions.
What mechanism that can triggers SIRS is r/t MI or pancreatitis? A. Abscess formation. B. Microbial invasion. C. Global perfusion deficits. D. Ischemic or necrotic tissue.
Ischemic or necrotic tissue. This mechanism triggers SIRS with MI, pancreatitis, and vascular disease. The abscess formation mechanism occurs with intraabdominal and extremity abscesses. The microbial invasion trigger is r/t bacteria, viruses, fungi, or parasites. Global perfusion deficits are seen post-cardiac resuscitation and in shock states.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? A. Dextrose 5% in water B. Dextrose 5% in 0.9% sodium chloride C. 0.9% sodium chloride D. Lactated Ringer's
LR Lactated Ringer's is used in the first 24 hr following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? A. Dextrose 5% in water B. Dextrose 5% in 0.9% sodium chloride C. 0.9% sodium chloride D. LR
LR. Lactated Ringer's is used in the first 24 hr following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? A. "Large incisions will be made in the eschar to improve circulation." B. "This procedure involves placing the client into a shower and removing the dead tissue." C. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area." D. "Dead tissue will be non-surgically removed."
Large incisions will be made in the eschar to improve circulation. An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation.
Which characteristics accurately describe chemical burns? SATA. A. Metabolic asphyxiation may occur. B. Metabolic acidosis occurs immediately following the burn. C. The visible skin injury often does not represent the full extent of tissue damage. D. Lavaging with large amounts of water is important to stop the burning process. E. Alkaline substances that cause this continue to cause tissue damage even after being neutralized.
Lavaging, Alkaline substances. Removing the chemical from the skin is important. Lavaging for 20 min - 2 hrs postexposure may be needed. Alkali tends to adhere to skin and causes prolonged damage. Metabolic asphyxiation is from inhalation of carbon monoxide or hydrogen cyanide. Metabolic acidosis is most common in electrical burns from the "iceberg effect."
When assessing a patient's full thickness burn during the emergent phase, what would the nurse expect to find? A. Leathery, dry, hard skin. B. Red, fluid-filled vessicles. C. Massive edema at the site. D. Serous exudate on a shiny, dark brown wound.
Leathery, dry and hard. Is found in the emergent phase and it may turn brown in the acute phase. Deep partial burns in the emergent phase are red and shiny and have blisters. Edema may not be as extensive in full thickness burns d/t thrombosed vessels.
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns? A. Age of the client B. Associated medical history C. Location of the burn D. Cause of the burn
Location of the burn. When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to assess the location of the burns that can lead to respiratory distress.
A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. B. Place the client in a supine position. C. Place a warming blanket on the client. D. Use log rolling to reposition the client.
Log rolling. Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned.
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury? A. Initiate fluid resuscitation. B. Medicate for pain. C. Insert an indwelling urinary catheter. D. Maintain the airway.
Maintain the airway. The client is at risk for respiratory obstruction. Using the airway, breathing, circulation approach to client care is the first action the nurse should take to ensure that the client has a patent airway.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Gradual onset of several hours B. Manifestations preceded by a severe headache. C. Maintains consciousness. D. History of neurologic deficits lasting less than 1 hr.
Manifestations preceded by a severe headache. A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke
A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? A. Albumin 25% B. Dextran 70 C. Hydroxyethyl glucose D. Mannitol 25%
Mannitol 25% The nurse should plan to administer mannitol 25%, an osmotic diuretic that lowers intracranial pressure by promoting diuresis.
A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% normal saline IV at 50 mL/hr continuous D. Bumetanide 1 mg IV bolus every 12 hr
NS at 50 ml/hr. 0.9% sodium chloride is isotonic and will not cause the fluid shift needed in this client to reduce circulatory overload. This prescription requires clarification.
A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? A. Determine the level at which the client had intact sensation B. Assess the level at which the client has retained mobility C. Check the blood pressure and pulse for signs of spinal shock D. Monitor respiratory effort and oxygen saturation level.
Monitor respiratory effort and O2. The first priority for the client with a spinal cord injury is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority.
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system? A. Auscultate cuff blood pressure. B. Palpate pulse pressure. C. Obtain a central venous pressure. D. Monitor the pulmonary artery pressure.
Monitor the pulmonary artery pressure. Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. The pulmonary artery pressure provides an accurate assessment of the cardiovascular system by detecting changes in both right and left heart pressure which can indicate possible development of pulmonary edema, as well monitor overall fluid status.
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Hypotension. B. Anuria. C. Narrowing pulse pressure D. Decreased LOC
Narrowing pulse pressure Pulse pressure is the difference between the systolic and diastolic blood pressures. In the initial stage of shock there is a slight increase in the diastolic blood pressure, which narrows the pulse pressure.
What type of shock occurs with PE or abdominal compartment syndrome? A. Distributive. B. Obstructive. C. Cardiogenic. D. Hypovolemic.
Obstructive. Occurs when a physical obstruction impedes the filling or outflow of blood, resulting in decreased CO. Distributive is evident with massive vasodilation and impaired cellular metabolism (neurogenic) or increased cap permeability (anaphylactic). Cardiogenic shock occurs when the systolic or diastolic dysfunction of the heart's pumping action results in decreased CO. Hypovolemic shock is the loss of blood or fluid.
A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take? A. Apply ice to the burns. B. Place the child in a tub of cool water. C. Pour tepid water over the burns. D. Cover the burns with a blanket
Pour tepid water. Tepid water reduces pain and swelling and conducts the heat of the burns away from the skin.
When a primary survey of a trauma client is conducted, what is one of the priority actions that would be performed first? A. Obtain a complete set of vital sign measurements. B. Palpate and auscultate the abdomen. C. Perform a brief neurologic assessment. D. Check the pulse oximetry reading.
Perform a brief neuro assessment. A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey.
An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? A. Extension of the arms B. Pronation of the hands C. Plantar flexion of the legs D. External rotation of the lower extremities
Plantar flexion of the legs. Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts.
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? A. Reduce edema of the brain B. Provide fluid hydration. C. Increase cell size in the brain. D. Expand extracellular fluid volume
Reduce edema to the brain. An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.
A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? A. Provide a nonskid mat to alleviate plate movement. B. Encourage the client to use his right hand when feeding himself. C. Remind the client to look for food on the left side of the tray. D. Encourage the use of the wide grip utensils.
Remind the client to look for food on the left side of the tray. The nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.
A nurse is teaching a group of clients about first aid care for a bee sting. Which of the following information should the nurse include in the teaching? A. Remove the stinger by scraping it off with a knife blade. B. Apply a tourniquet. C. Apply a warm pack. D. Suck the wound
Remove by scraping. The nurse should instruct the clients to scrape the stinger off with a firm, straight edge to decrease additional venom from injecting into the client's tissue.
A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion? A. Photophobia B. Nuchal rigidity C. Positive Kernig's sign D. Restlessness
Restlessness. Clients who have meningitis can be at risk for developing increased ICP. The nurse should monitor the client's vital signs and neurological status at least every four hours. Indications of increased ICP include increased restlessness and confusion, a decreased level of consciousness, and the presence of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia).
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness
Restlessness. Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.
A 70 y/o pt is malnourished, has T2DM, and is admitted from the nursing home with pneumonia and tachypnea. What kind of shock should the nurse monitor for? A. Septic. B. Neurogenic. C. Cardiogenic. D. Anaphylactic.
Septic. Older adults with chronic diseases and malnourished or debilitated pts are at risk for septic shock, especially when they have an infex. Fever, hypothermia, tachycardia, tachypnea, altered mental status, significant edema, hyperglycemia without DM are also criteria for dx sepsis.
What indicators of tissue perfusion should should be monitored in critically ill pts by the nurse? SATA. A. Skin. B. UO. C. LOC. D. ADLs. E. VS and pulse ox. F. peripheral pulses with cap refill.
Skin, UO, LOC, VS, pulses and cap refill.
A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse? A. Slow the rate to 20 mL/hr. B. Continue the rate at 125 mL/hr. C. Slow the rate to 50 mL/hr. D. Increase the rate to 250 mL/hr.
Slow the rate to 50 ml/hr. The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and prevent increased intracranial pressure.
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands. B. The client is unable to make vocal sound. C. The client is unconscious. D. The client opens his eyes when spoken to.
The client opens eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.
A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? A. Edematous bruise on forehead B. Small drops of clear fluid in left ear C. Pupils are 4 mm and reactive to light D. Glasgow Coma Scale (GCS) score of 12
Small drops of clear fluid in the L ear. Clear fluid in the ear canal might be cerebrospinal fluid (CSF) and indicates a basilar skull fracture. CSF drainage is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents. This finding should be reported to the provider.
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? A. Assign assistive personnel to keep his room neat and clean. B. Rotate nursing staff so he can have varied interactions. C. Talk with the client during wound care. D. Keep family members aware of his condition.
Talk during wound care. Talking with the client while providing care assists in the development of the nurse-client relationship and demonstrates caring.
Which burn pt should have OT or ET intubation? A. Carbon monoxide poisoning. B. Electrical burns causing cardiac dysrhythmias. C. Thermal burn injuries to the face, neck, airway. D. Resp distress from eschar formation around chest.
Thermal burns to the face, neck, airway. This requires intubation 1-2 hrs after injury to prevent the need for emergent tracheostomy. Carbon monoxide is tx with 100% O2. Eschar constriction of the chest is tx with an escharotomy.
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score? A. The client needs total nursing care. B. The client is alert and oriented. C. The client is in a deep coma. D. Indicates stable neurologic status.
Total nursing care. A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care.
The nurse initially suspects the possibility of sepsis in the burn patient based on what changes? a. Vital signs b. Urinary output c. Gastrointestinal function d. Burn wound appearance
VS. Early sx of sepsis include an elevated temp, increased pulse and RR accompanied by decreased BP and later, decreased UO and perhaps paralytic ileus. A burn wound may become locally infected without causing sepsis.
What position should the nurse place the pt in if they have ear, face and neck burns? A. prone. B. on the side. C. without pillows. D. with extra padding around the head.
Without pillows. Pts with ear burns are not allowed to use pillows bc of the danger of sticking to the pillowcase, and pts with neck burns are not allowed to use pillows due to contractures of the neck.
What interventions should be used for anaphylactic shock? SATA. A. Antibiotics. B. Vasodilators. C. Antihistamines. D. O2 supplementation. E. Colloid volume expansion. F. Crystalloid volume expansion.
antihistamines, O2, colloids, crystalloids. Epi is also frequently used. Only septic shock is tx with abx. Vasodilators and inotropes are only for cardiogenic shock. Volume expansion fluids vary with each type of shock.
What physical problems could precipitate hypovolemic shock? SATA A. Burns. B. Ascites. C. Vaccines. D. Insect bites. E. Hemorrhage. F. Ruptured spleen.
burns, ascites, hemorrhage, ruptured spleen. Hypovolemic shock occurs when there is a loss of a volume of fluid, fluid shift, or internal bleeding. Vaccines and insect bites would precipitate anaphylactic shock.
After emergency endotracheal intubation, the health care team and the nurse must verify tube placement before securing the tube. What is the most accurate bedside assessment that can be performed immediately after the tube is placed? A. Visualize the movement of the thoracic cage. B. Auscultate the chest during assisted ventilation. C. Confirm that the breath sounds are equal and bilateral. D. check exhaled carbon dioxide levels with capnography.
check exhaled carbon dioxide levels with capnography. Checking exhaled carbon dioxide levels is the most accurate way of immediately verifying placement. Observing chest movements and auscultating and confirming equal bilateral breath sounds are considered less accurate. (Note to student: Possibly, you may see the health care team auscultating the chest; this is a long-time practice that is quick to perform and doesn't harm the client if used in conjunction with other verification methods.) Radiographic study will verify and document correct placement.
What is a key factor in describing any type of shock? A. hypoxemia. B. hypotension. C. vascular collapse. D. inadequate tissue perfusion.
inadequate tissue perfusion. Although all of these may be present, regardless of the cause, the end result is inadequate supply of O2 and nutrients to body cells from inadequate perfusion.
A pt with severe trauma has been tx for hypovolemic shock. The nurse recognizes that the pt is in the refractory stage of shock when what is found on assm? A. Resp alkalosis with a pH of 7.46. B. Marked hypoTN and refractory hypoxemia. C. Unresponsiveness that responds only to painful stimuli. D. Profound vasoconstriction with absent peripheral pulses.
marked hypoTN and refractory hypoxemia. During both compensatory and progressive stages, the SNS is activated in attempt to maintain CO and SVR. In the refractory stage, the SNS can no longer compensate. Resp alkalosis occurs in early shock. Unresponsiveness and absent pulses can occur for many reasons early in shock.
What sx indicate to the nurse that the pt is in the compensatory stage of shock? SATA. A. pale and cool. B. unresponsive. C. lower BP than baseline. D. moist crackles in lungs. E. hyperactive bowel sounds. F. tachypnea and tachycardia.
pale and cool, lower BP, and tachys. In the compensatory stage, the pt's skin will be pale and cool. There may also be a change in LOC, but the pt will be responsive. The BP will be lower than baseline, bowel sounds will be hypoactive and tachys will occur. Unresponsive and moist crackles in the lungs occur in the progressive stage.
During the rehab phase of a burn, what can control the contour of the scarring? A. pressure garments. B. avoiding sunlight. C. splinting joints in extension. D. application of emollient lotions.
pressure garments. This helps to keep scars flat and prevent elevation and enlargement above the original burn injury area. Avoidance of sunlight is necessary for at least 3 months to prevent hyperpigmentation and sunburn. Water-based lotions and splinting are used to prevent contractures.
The nurse suspects sepsis as the cause of shock when labs indicate... A. hypoK. B. thrombocytopenia. C. decreased hemoglobin. D. increased BUN.
thrombocytopenia. Endotoxin simulates a cascade of inflamm responses that start with the release of RNF and Interleukin-1. The release of platelet-activating factor causes formation of microthrombi and vessel obstruction. There is vasodilation, increased cap permeability, neutrophil and platelet aggregation, and adhesion to the endothelium. This does not occur in other types of shock.
