CC3 (B)

26. The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurses. What causes this? Why does it hurt so much?" The nurse should answer A. Pancreatitis is causes by diabetes you should be checked B. Pancreatitis is extremely rare, and no one knows why it causes pain C. The pain is localized to the pancreas. Fortunately it will not affect anything else. D. Injury to certain cells in the pancreas causes it to digest (eat) itself causing pain.

D. Injury to certain cells in the pancreas causes it to digest (eat) itself causing pain.

30. A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs as a result of what pathophysiological mechanism? A. Loss of storage capacity for senescent red blood cells B. Release of glycogen into the serum, resulting in hyperglycemia C. Uncontrolled hypoglycemia caused by an increased release of insulin D. Premature activation of inactive digestive enzymes, resulting in autodigestion.

D. Premature activation of inactive digestive enzymes, resulting in autodigestion.

46. The nurse is caring for a patient with acute liver failure. What laboratory value would the nurse expect to decrease in this situation? a. Albumin b. Alkaline phosphatase c. Aspartate aminotransferase d. Total bilirubin

a. Albumin

18. The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? Select all that apply a. Disseminated intravascular coagulation b. Hyperalbuminemia c. Ascites d. Malnutrition e. Hypoglycemia

a. Disseminated intravascular coagulation c. Ascites d. Malnutrition

10. The nurse is concerned about a deteriorating patient. What signs of cardiogenic shock does the nurse expect? Select all that apply a. Heart rate 126 beats/min b. Blood pressure 86/42 mg Hg c. Urine output 20 ml/hr d. Bounding pedal pulse (weak pedal pulses) e. Cool and moist skin

a. Heart rate 126 beats/min b. Blood pressure 86/42 mg Hg c. Urine output 20 ml/hr e. Cool and moist skin

21. The nurse is talking to a client and his family about hepatitis. Which of the following statements by a family member indicate understanding of the nurse's teaching? (SATA) a. Hepatitis B is preventable with a vaccine series. b. Patients with blood transfusion or solid organ donation prior to 1992 are at higher risk for developing hepatitis. c. Hugging, kissing, holding hands, coughing or sneezing can spread hepatitis C. d. Patient having unprotected sex are at risk for developing Hepatitis A (hep B & C) e. You should get tested for hepatitis if you inject drugs, even if it was just once or many years ago.

a. Hepatitis B is preventable with a vaccine series. b. Patients with blood transfusion or solid organ donation prior to 1992 are at higher risk for developing hepatitis. e. You should get tested for hepatitis if you inject drugs, even if it was just once or many years ago.

41. A patient was admitted with pancreatitis. In which order would the nurse perform an assessment of the gastrointestinal system? a. Inspection, auscultation, percussion, palpation b. Palpation, percussion, inspection, auscultation c. Palpation, inspection, auscultation, percussion d. Inspection, palpation, percussion, auscultation

a. Inspection, auscultation, percussion, palpation

24. The nurse is caring for a patient in the ICU. When caring for the patient, he notices the rhythm attached. The patient's vital signs included T 97.9 F, HR 115, RR 19, BP 132/74 mm Hg, and O2 sat 93% on room air. The nurse identifies this rhythm as? a. Multifocal premature ventricular contraction b. Ventricular tachycardia c. Atrial fibrillation d. Unifocal premature ventricular contraction

a. Multifocal premature ventricular contraction

37. After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mmHg but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. Norepinephrine (vasopressin; increase blood pressure) b. Sodium nitroprusside (cardiogenic shock increase MAP) c. Furosemide (cardiogenic shock) d. Nitroglycerin (cardiogenic shock increase MAP)

a. Norepinephrine (vasopressin; increase blood pressure)

9. A 45 year old female patient has superficial burns on the posterior head and neck, front and back of the right arm, posterior trunk, front and back of the left leg and back of the right leg. The patient weighs 60 kg. Use the parkland burn formula to calculate the total amount of lactate ringeners that will be given the next 24 hours? a. 16,200 mL b. 14,040 mL c. 12,960 mL d. 11,880 mL

b. 14,040 mL

39. The patient is admitted for syncope to the hospital. When the ED RN puts the patient on the cardiac monitor what rhythm is observed? (PICTURE) a. First degree AV-Block b. 2nd degree type 2 AV-Block c. Sinus bradycardia d. Complete or 3rd degree AV-Block

b. 2nd degree type 2 AV-Block

2. A patient is being treated or bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Verify the position of the balloon every hour. b. Keep scissors at bedside c. Monitor the patient for gag reflex d. Instruct the patient to cough every hour

b. Keep scissors at bedside

50. The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient? a. Lorazepam b. Lactulose c. Insulin d. Vitamin K

b. Lactulose

49. Nursing priorities for the management of acute pancreatitis include (SATA) a. Stimulating gastric content motility into duodenum b. Managing respiratory dysfunction c. Withholding analgesics that could mask abdominal discomfort d. Assessing and maintaining electrolyte balance e. Utilizing supportive therapies aimed at decreasing gastrin release

b. Managing respiratory dysfunction d. Assessing and maintaining electrolyte balance e. Utilizing supportive therapies aimed at decreasing gastrin release

4. At the end of the emergency phase and the initial phase of burn, a patient has a serum sodium level of 152 mEq/L (152) mmol/L), and a serum potassium level of 2.8 mEq/L (2.8 mmol/L). What could have caused these imbalances? a. Free oral water intake b. Mobilization of fluid and electrolyte in the acute phase c. Prolonged hydrotherapy d. Excessive fluid replacement with dextrose in water without potassium supplement

b. Mobilization of fluid and electrolyte in the acute phase At the end of the emergent phase, fluid mobilization moves potassium back into the cells and sodium returns to the vascular space, causing hypokalemia and hypernatremia. As diuresis in the acute phase continues, sodium will be lost in the urine and potassium will continue to be low unless it is replaced. Excessive fluid replacement with 5% dextrose in water without potassium supplementation can cause hyponatremia with hypokalemia. Prolonged hydrotherapy and free oral water intake can cause a decrease in both sodium and potassium

34. When shock occurs in a patient with pulmonary embolism or abdominal compartment syndrome, what type of shock would that be? a. Cardiogenic b. Obstructive c. Distributive d. Hypovolemic

b. Obstructive

36. Select the patient below who is at MOST risk for complication 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 36 year old male with full thickness burns on the front of the left arm c. A 25 year old female with partial thickness burns on the front of the head and neck and front and back of the torso d. A 10 year old with superficial burns on the right leg

c. A 25 year old female with partial thickness burns on the front of the head and neck and front and back of the torso

16. A patient with acute pancreatitis is complaining of pain in the left upper quadrant. Using a 1 to 10 pain scale, the patient states current level is an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control? a. Administer analgesics b. Teach relaxation and distraction techniques c. Administer analgesics around the clock d. Educate the patient and family on lifestyle changes

c. Administer analgesics around the clock

29. Which of the following best describes multiple organ dysfunction syndrome (MODS)? a. Loss of function of two or more components of the same organ system b. Sepsis involving two or more organ system c. Cessation of function of two or more organ system d. Progressive insufficiency of two or more organ systems.

c. Cessation of function of two or more organ system

22. What is the initial cause of hypovolemia during the emergent phase of burn? a. Fluid loss from denuded skin surfaces b. Loss of sodium to the interstitial c. Increases capillary permeability d. Decreases vascular oncotic pressure

c. Increases capillary permeability

11. When administering any vasoactive drug during the treatment of shock, what should the nurse recognize as the goal of the therapy? a. Constriction of vessel to maintain BP b. Dilating vessels to improve tissue perfusion c. Maintaining a mean arterial pressure (MAP) greater than 65 mmHg d. Increasing urine output to 50 mL/hr

c. Maintaining a mean arterial pressure (MAP) greater than 65 mmHg

47. A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following laboratory findings should the nurse expect? a. Presence of immunoglobulin G antibodies (IgG) b. Aspartate aminotransferase (AST) 35 units/L c. Positive EIA test d. Alanine aminotransferase (ALT) 15 IU/L

c. Positive EIA test The presence of enzyme immunoassay is an expected laboratory finding in a client who has a new diagnosis of hepatitis C.

7. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What manifestation would the nurse expect the practitioner to order for this patient? a. Histamine (H2) antagonists b. Heparin c. Vasopressin d. Antacids

c. Vasopressin

20. Using the "rule of nines", calculate the percent of injury in an adult who was injured as follows: the patient sustained partial- and full-thickness burns to half of his left arm anteriorly, his entire left leg, and his perineum. a. 45.5% b. 28% c. 16% d. 23.5%

d. 23.5%

17. The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should a. Only use crystalloid fluids to prevent IV lines from clotting. (can also use colloid) b. Avoid the use of colloid IV solutions in managing the patient's fluid status. c. Restrict intravenous and oral fluid intake because of fluid shifts d. Monitor the patient's blood pressure and evaluates for signs of dehydration

d. Monitor the patient's blood pressure and evaluates for signs of dehydration

A patient with alcoholic liver disease has severe anemia in the ICU. The nurses notice the patient is unresponsive, pulseless and initiates code blue. The nurse should recognize this rhythm as? a. Ventricular fibrillation b. Idioventricular rhythm c. Pulseless electrical activity d. Torsades de pointes

d. Torsades de pointes

5. Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Ask the patient to extend both arms forward. Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. b. Request that the patient stand on one foot. c. Request that the patient walk with one eye closed. d. Ask the patient to perform the valsalva maneuver.

a. Ask the patient to extend both arms forward. Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy.

14. Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Daily assess the need for the central IV catheters b. Change the peripheral IV catheter every 14 days (should be 3-7 days) c. Maintain strict aseptic technique during burn wound management d. Apply topical antibacterial wound ointment dressings e. Restrict family visitation

a. Daily assess the need for the central IV catheters c. Maintain strict aseptic technique during burn wound management d. Apply topical antibacterial wound ointment dressings

38. A 44 year old woman diagnosed with sepsis develops petechiae, ecchymosis, mucosal oozing, and hematuria. Her prothrombin time (PT) and activated partial thromboplastin time (aPTT) are prolonged but she is not reaching anticoagulant therapy. The most likely cause of these changes is: a. Disseminated intravascular coagulation (DIC) pg 1575 b. Hepatic failure c. Platelet dysfunction d. Systemic inflammatory response syndrome (SIRS)

a. Disseminated intravascular coagulation (DIC) pg 1575

45. Which type of burn injury would cause myoglobinuria, long bone fractures, dysrhythmias, and/or cardiac arrest? a. Electrical b. Thermal c. Smoke and inhalation d. Chemical

a. Electrical

40. Which nursing intervention is priority for a patient with gastrointestinal hemorrhage? a. Ensuring the patient has patent airway b. Maintaining venous access so that the fluids and blood can be administered. c. Positioning the patient in a high-Fowler position d. Irrigating the nasogastric tube with iced saline

a. Ensuring the patient has patent airway

1. Your patient just returned from an emergent CT with contrast of the abdomen for suspicion of acute pancreatitis. Upon arrival she is complaining of tongue swelling and difficulty breathing. You should immediately anticipate a. Epinephrine 0.3 mg IM b. Epinephrine 1 mg IV c. Diphenydramine 50 mg IV d. Methylprednisolone 125 mg IV

a. Epinephrine 0.3 mg IM

19. The nurse is caring for a patient with acute liver failure. The practitioner asks the nurse to assess the patient for asteriosis. How should the nurse assess this for this symptom? a. Have the patient extend the arms and dorsiflex the wrist b. Inflate a blood pressure cuff on the patient's arm c. Dorsiflex the patient's foot d. Have the patient bring the knees to the chest.

a. Have the patient extend the arms and dorsiflex the wrist

28. Which indicators of tissue perfusion should the nurse monitor in critically ill patients? (SATA) a. Peripheral pulses with capillary refill b. Vital signs including pulse oximetry c. Level of consciousness d. Skin e. Urine output

a. Peripheral pulses with capillary refill b. Vital signs including pulse oximetry c. Level of consciousness d. Skin e. Urine output

23. A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? Select all that apply a. Serum glucose b. Serum amylase c. Potassium decreases d. White blood cells e. Calcium decreases

a. Serum glucose b. Serum amylase d. White blood cells

44. The nurse understands that the following outcome should be assessed for a septic shock patient? (SATA) a. The nurse understands that there is not one specific lab that will indicate sepsis is occuring pg 1575 b. Increase in CO and CI in the compensatory stage c. Use of a broad spectrum IV antibiotic within the 1st hour pg 1579 d. Higher risk for bleeding e. Obtaining serum Lactate and Procalcitonin level

a. The nurse understands that there is not one specific lab that will indicate sepsis is occuring pg 1575 c. Use of a broad spectrum IV antibiotic within the 1st hour pg 1579 d. Higher risk for bleeding e. Obtaining serum Lactate and Procalcitonin level

48. The occurrence of acute liver failure is most common in which situation? a. Use of acetaminophen with alcohol use b. An individual with hepatitis A c. Antihypertensive medication use d. An individual with hepatitis C

a. Use of acetaminophen with alcohol use

8. A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns of the neck, and chest. While planning the client's care, the nurse should be aware that initially the client is the greatest risk for which of the following? a. Fluid imbalance b. Airway obstruction c. Infection d. Paralytic ileus

b. Airway obstruction

43. The nurse is reviewing discharged instructions of a patient who is 4 days post-heart valve surgery, when the bedside ECG monitor alarms loudly and displays the following sustained ECG rhythm. Which intervention should the nurse implement first? a. Prepare to defibrillate the patient b. Check for a pulse c. Obtain a 12 lead ECG d. Administer lidocaine an antiarrhythmic (IVP)

b. Check for a pulse

6. When taking the blood pressure (BP) on the right arm on a patient with 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. Check the calcium level in the chart. c. Notify the healthcare provider immediately. d. Retake the patient's blood pressure

b. Check the calcium level in the chart.

31. Which prescribed drug is best for the nurse to give before scheduled debridement on a patient with partial-thickness burns? a. Ketorolac b. Hydromorphone (Dilaudid) c. Acetaminophen d. gabapentin (Neurontin)

b. Hydromorphone (Dilaudid)

15. A patient with acute pancreatitis is NPO and has a gastric tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? a. Grey Tuner;s sign resolved. b. Bowel sounds are present. c. Abdominal pain is decreased. d. Electrolytes levels are normal

c. Abdominal pain is decreased.

27. A patient presents to the ER with a sudden onset of lip swelling, facial edema and throat tightness after eating shellfish. The nurse anticipates which of the following to be administered first to the patient based on their signs and symptoms? a. High flow oxygen b. Albuterol via nebulizer mask c. Epinephrine d. Corticosteroids

c. Epinephrine

13. A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to: a. Continue to monitor the patient b. Increase the IV fluids c. Notify the physician of this finding normal urine output is 30 mL/hr d. Decrease the IV fluids

c. Notify the physician of this finding normal urine output is 30 mL/hr

35. A patient is admitted with a gastrointestinal hemorrhage due to esophageal varices. The nurse knows that the varices are caused by which pathophysiologic mechanism? a. Breakdown the mucosal resistance b. Inflammation and ulceration c. Portal hypertension d. Superficial mucosal erosions

c. Portal hypertension

33. A nurse is assessing a patient with pancreatitis and suspects of Grey Turner sign when which of the following is exhibited? a. Left abdominal pain that occurs with movement b. Bluish discoloration of the periumbilical area c. Jaundice of the sclera d. Bluish discoloration of the flank area

d. Bluish discoloration of the flank area

32. What is the key factor in describing any type of shock? a. Vascular collapse b. Hypotension c. Hypoxemia d. Decreased tissue perfusion

d. Decreased tissue perfusion

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

d. High calorie, high protein and iron supplements

25. A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Focal injury cerebral hemispheres b. Injury to the hypothalamus c. Parasympathetic nervous system stimulation d. Loss of sympathetic nervous system innervation .

d. Loss of sympathetic nervous system innervation . Neurogenic shock can be caused by anything that disrupts the sympathetic nervous system (SNS). The problem can occur as the result of interrupted impulse transmission or blockage of sympathetic outflow from the vasomotor center in the brain. The most common cause is spinal cord injury (SCI).

42. A patient with severe trauma has been treated for hypovolemic shock. Which assessment finding is consistent with the refractory stage of shock? a. Profound vasoconstriction with absent peripheral pulses. b. A respiratory alkalosis with a pH of 7.46 c. Unresponsiveness that responds only to painful stimuli d. Marked hypotension and refractory hypoxemia

d. Marked hypotension and refractory hypoxemia