EXAM 4

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Autonomic Dysreflexia

(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)

how do we treat a high ventilation?

- ambu bag - bipap

what is the worst score you can get with Glasgow scale ?

what does primary survey for p include?

Pain assessment and management

how do we take care of the patients airway before we place an ET tube?

bag valve asks and oral airway adjunct

IV air vents

below the spike !!!

what is an example of a mass causality incident

car pile up

how do we confirm placement of the chest tube ?

chest X-ray

how do we diagnose fat emboli syndrome

getting lipids in the blood stream

what is the most common blunt force trauma injury

motor vehicle crashes

do we need a c spine? if patient complains of neck pain

yes

do we need a c spine? patient has neck pain, LOC changed and non verbal

yes

why should we be careful holding pressure to neck bleeds?

you can drop the blood pressure on that side which isnt good

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.

a fracture that does not move, stays in place and is non displaced a. linear fracture b. no displaced fracture c. depressed skull fracture d. basilar skull fracture

emergency operations plan and incident command system a. preparedness b. recovery c. mitigation d. response

for the care of this fracture, you need to elevate HOB to 30 degrees a. basilar skull fracture b. maxillary fracture

the patient with a grade V liver laceration is hemodynamically unstable. The nurse prepares the patient for which intervention? a. Operative management b. Admission to the hospital c. CT scan with contrast d. Angiography

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Brief neurologic assessment B. Client's allergy history C. Initiation of pulse oximetry D. Complete set of vital signs

a - A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. - everything else is done In the second survey

Which patient being cared for in the emergency department should the charge nurse evaluate first? a.A patient with a complete spinal injury at the C5 dermatome level b.A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c.An alert patient with a subdural bleed who is complaining of a headache d.An ischemic stroke patient with a blood pressure of 190/100 mm Hg

a - A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.

The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a. Placement of an intraosseous catheter b. Placement of a central line placement c. Insertion of a femoral catheter by a trauma surgeon d. Rapid transfer to the operating room

a - Infusion of volume is required for optimal fluid resuscitation and may be achieved through large caliber venous cannulation or intraosseous access. A central line or femoral vein access may be obtained by the physician, but the procedure requires time. Transport to the operating room is not a priority in the goal to obtain intravenous access for fluid resuscitation.

Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture? a. Insertion of a nasogastric tube b. Insertion of an indwelling urinary catheter c. Endotracheal intubation d. Placement of an oral airway

a - Nasogastric tubes are contraindicated in basilar skull fractures because insertion may result in penetration of the meninges. An indwelling urinary catheter may be necessary to monitor fluid balance. Protection of the airway to include placement of an oral airway or endotracheal tube may be indicated.

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 - 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.

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 - The answer is A. 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 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 - this will decrease edema and prevent compartment syndrome

During the E. exposure and environment phase of the Trauma Nurse Process, the main interventions include (select all that apply) a. Keep patient warm b. Remove all remaining clothing c. Obtain laboratory studies d. Consider radiographic imaging e. Assess Blood glucose levels

a and b

What are some patient priorities during the emergent phase of burn management? A. Fluid volume B. Respiratory status C. Psychosocial D. Wound closure E. Nutrition

a and b

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a. Crush injury to right arm b. Gunshot wound to the abdomen c. Lightning strike of the left arm and chest d. Pulmonary contusion and rib fracture

a and c

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patients plan of care? (Select all that apply.) a.Make frequent neurological assessments. b.Maintain CO2 level at 50 mm Hg. c.Maintain MAP less than 130 mm Hg. d.Prepare for thrombolytic administration. e.Restrain affected limb to prevent injury.

a and c - The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.

During the F. phase of the Trauma Nurse Process, the nurse would (Select all that apply) a. Find out about a family member b. Get pastoral care c. Evaluate laboratory results d. Obtain full set of VS and on a regular interval e. Get CT of the head

a and d

we would measure the pressure of the abdomen for compartment syndrome with what?

a foley that is connected to a transducer

we would measure the pressure of the leg for compartment syndrome with what?

a machine that looks at the pressure

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

a, b, c

In preparation to receive the trauma patient, the trauma nurse would: (select all that apply) a. Make sure equipment is in the room and functioning b. Prepare for interventions that are likely to occur c. Prepare lighting and room temperature d. Have radiology in the room for imaging e. Have technician in the room for venipuncture

a, b, c

Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also due to the patients' long-term management. Which of the following statements apply to trauma patients? (Select all that apply.) a. Indwelling urinary catheters are a source of infection b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection.

a, b, c

Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered c. Administration of potassium as ordered d. Administration of calcium as ordered

a, b, d

What are interventions related to musculoskeletal injuries? (Select all that apply) a. Rest b. Compress c. Antibiotics d. Ice e. Elevate f. Heat

a, b, d, e

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? 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, b, d, e, f

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 positon. 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, b, d, f

A patient is receiving mechanical ventilation with PEEP. The patient had developed a tension pneumothorax. Select ALL the signs and symptoms that can present with this condition: A. Hypotension B. Jugular Venous Distention C. Bradycardia D. Tracheal deviation E. Hyperemia F. Tachypnea

a, b, d, f

The nurses notes a large leg laceration that has significant bleeding. Which of the following are immediate interventions to apply to this situation? Select all that apply a. Elevate the affected extremity b. Call the OR c. Apply pressure to the arterial site d. Apply pressure to the laceration site e. Assess HGB and HCT

a, c and d

During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air

a, c, d

Which of the following findings require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury? (Select all that apply.) a. Mean arterial pressure 48 mm Hg b. Elevated serum blood alcohol level c. Non-reactive pupils d. Respiratory rate of 10 breaths per minute

a, c, d - rapid assessment of patients with neurological injury is vital to the treatment of patients with traumatic brain injury. Preventing hypotension (mean arterial pressure less than 50 mm Hg) is essential to maintain cerebral perfusion; non-reactive pupils are an abnormal finding and require immediate attention to evaluate the cause. Adequate oxygenation and ventilation are necessary to deliver oxygen to the brain; thus, a respiratory rate of 10 requires further evaluation. An elevated blood alcohol level interferes with the ability to conduct a neurological examination but does not require immediate intervention.

What interventions are done during the D. disability phase of the Trauma Nurse Process and rationale? Select all that apply a. Assess need for CT of head with any changes in LOC - increase in intracranial pressure b. Consider transferring to another facility c. Bedside glucose, EtOH and toxicology screening that can alter neurological status d. Remove all clothing e. Consider ABGs for hypoxia or hypercapnia that can alter neurological status

a, c, e

A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia What signs and symptoms will you educate the patient about? Select all that apply: A. Headache B. Low blood glucose C. Sweating D. Flushed below site of injury E. Pale and cool above site of injury F. Hypertension G. Slow heart rate H. Stuffy nose

a, c, f, g, h - All of these are signs and symptoms of autonomic dysreflexia. The patient will have flushing above site of injury due to vasodilation from parasympathetic activity, BUT will be pale and cool below site of injury due to vasoconstriction occurring below the site of injury for the sympathetic response reflex.

The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate? a. Insert an oral airway to prevent aspiration and to protect the airway. b. Offer the patient an emesis basin so that you can measure the amount of emesis c. Prepare to suction the oropharynx while maintaining cervical spine immobilization. d. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a.pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b.pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c.pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d.pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a.Altered cerebral spinal fluid production and reabsorption b.Decreased cerebral blood volume due to vessel constriction c.Increased cerebral blood volume due to vessel dilation d.No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a.The patient is exhibiting extension posturing. b.The patient is exhibiting flexion posturing. c.The patient is exhibiting purposeful movement. d.The patient is withdrawing to stimulation.

The orienting nurse is performing insertion of a urinary catheter on an MVC patient. The preceptor stops the orientee from performing the insertion. Which of the following responses from the orienting nurse would indicate understanding of stopping the insertion? a. I should not insert a urinary catheter on MVC patients because of CAUTI rates. b. I should not insert a urinary catheter on this patient because we do not have an order. c. I should not insert a urinary catheter on this patient due to blood at the meatus. d. I should not insert a urinary catheter on this patient due to the hard, board like abdomen.

The patient arrives to the ER with burns to the mouth, singed nose and facial hair and a hoarse voice. The nurse prepares for which intervention? a. Oral airway b. LR at 500 mL c. Intubation and ventilation d. Pain management with Morphine 2 mg

The patient with a hemothorax and a chest tube are being transported for a CT scan. The new nurse puts the chest tube on the bed. What is the best response by the charge nurse to the new nurse? a. What are you doing? That does not belong there! b. The chest tube needs to be kept below the level of the heart to promote drainage c. The chest tube needs to be kept below the level of the heart to minimize high pressure in the pleural space d. The chest tube can be easily dislodged if it sits on the bed

The purpose of triage is to: a. Using a color coded system for all providers to identify patients at need immediate attention b. Quick and rapid method to sort patients for the most good to the greatest number of providers c. Quick and rapid method to sort patients when numbers overwhelms the current resources d. Rank and sort patients for the greater good

The unresponsive patient with facial injuries needs an adjunct airway until definitive airway can be established. Which airway would be the most appropriate for this patient? a. Tracheostomy b. Non Rebreather mask c. Oropharyngeal d. Nasopharyngeal

The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second, and is able to obey your commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for: a.acute kidney injury. b.acute respiratory distress syndrome. c.infection. d.stress ulcers.

Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a. 30 mL/hr. b. 50 mL/hr. c. 100 mL/hr. d. 300 mL/hr.

What remains the highest priority in a trauma patient with a mangled extremity? a. Salvaging the extremity b. Airway management c. Hemorrhage control d. The MESS score

When attending a client with a head and neck trauma following a vehicular accident, the nurse's initial action is to? A. Provide oxygen therapy B. Initiate intravenous access C. Immobilize the cervical area D. Do oral and nasal suctioning

When would the nurse obtain lab studies, monitoring devices, NGT/OGT consideration, and pain management during the Trauma Nurse Process? a. During the secondary survey under the pre hospital report b. During the primary survey under the D. disability c. During the primary survey under the G. get monitoring devices and give comfort d. During the secondary survey under the head to toe assessment

Which of the following best defines the term traumatic injury? a. All trauma patients can be successfully rehabilitated. b. Traumatic injuries cause more deaths than heart disease and cancer. c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d. Trauma mainly affects the older adult population.

Which of the following is a LATE sign of the development of a tension pneumothorax? A. Hypotension B. Tachycardia C. Tracheal deviation D. Dyspnea

Which patient would be at the highest risk for compartment syndrome? a. The 18 year old with a closed femur fracture and hare line traction b. The 68 year old with a history of dementia and hypertension with a tibia fracture c. The 72 year old with a history of A fib and MI with a humerus fracture d. The 22 year old intubated patient with lower right rib fractures

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patients left naris. What is the best nursing action? a.Have the patient blow the nose until clear. b.Insert bilateral cotton nasal packing. c.Place a nasal drip pad under the nose. d.Suction the left nares until the drainage clears.

While caring for a patient with a suspected pneumothorax, you note there are several areas on the patient's skin that appear to be "bulging" out. These "bulging" areas are located on the patient's neck, face, and abdomen. On palpation on these areas, you note they feel "crunchy". When charting your findings you would refer to this finding as? A. Subcutaneous paresthesia B. Pigment molle C. Subcutaneous emphysema D. Veisalgia

Who is in charge of positioning the patient in spinal immobilization? a. The physician b. The team leader c. The person at the head d. The charge nurse

You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient's last tetanus shot is unknown. Which of the following is the priority nursing diagnosis? A. Impaired Skin Integrity related to puncture wounds B. Ineffective Health Maintenance related to immunization status C. Risk for Infection related to organisms specific to cat bites D. Risk for Impaired Mobility related to potential tendon damage

You're providing care to a patient with a pneumothorax who has a chest tube. On assessment of the chest tube system, you note there is no fluctuation of water in the water seal chamber as the patient inhales and exhales. You check the system for kinks and find none. What is your next nursing action? A. Keep monitoring the patient because this is a normal finding. B. Increase wall suction to the system until the water fluctuates in the water seal chamber. C. Assess patient's lung sounds to assess if the affected lung has re-expanded. D. Notify the physician.

You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first? A. Green B. Yellow C. Red D. Black

Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action? A. Perform a bladder scan B. Perform a rectal digital examination C. Assess the patient's blood pressure D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.

knowledge to reduce loss of life and property loss - lessons learned - learn from real life events and drills a. preparedness b. recovery c. mitigation d. response

pieces of fractured bone extend below the surface of the skull and can compress the brain and possible cause a dura matter laceration a. linear fracture b. no displaced fracture c. depressed skull fracture d. basilar skull fracture

the client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury? A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Full-thickness deep

In patients with extensive burns, edema occurs in both burned and unburned areas because of: a.catecholamine-induced vasoconstriction. b.decreased glomerular filtration. c.increased capillary permeability. d.loss of integument barrier.

c - Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third spacing).

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5 F. Which physician order should the nurse institute first?a.Blood cultures (2 specimens) for temperature > 101 F b.Acetaminophen (Tylenol) 650 mg per rectum c.500 mL albumin infusion intravenously d.Decadron 20 mg intravenous push every 4 hours

c - Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

if the patient is not breathing how do we proceed?

ambu bag and oral airway until ET is palce

unequal pupils indicate what?

an issue with increased intracranial pressure

A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? a. Blood pressure 82/60, heart rate 122, respiratory rate 28. b. Crackles (rales) on auscultation of bilateral lung fields. c. Responsive only to painful stimuli. d. Irregular heart rate and rhythm.

A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN? A. Cleansing the amputated digits and placing them directly into an ice slurry B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water C. Gently cleansing the amputated digits and the hand with povidone-iodine D. Cleansing the digits with sterile normal saline and placing it in a sterile cup with sterile normal saline

A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a "sucking" sound when the patient inhales and exhales. The patient's chest x-ray shows a pneumothorax. What type of pneumothorax is this known as? A. Closed pneumothorax B. Open pneumothorax C. Tension pneumothorax D. Spontaneous pneumothorax

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

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing

During the TNP, when there is an issue in the primary survey, the issue is: a. Address issue and stop all assessments b. Addressed before moving on to other assessments c. Transfer to another facility d. Other assessments are completed and return to the issues to address

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

For the next 7 questions, use the START method for adults to help triage the wounded that have been involved in a disaster situation. Each question will give you details on what you have assessed and you will need to use those details to help you assign a color tag to the individual: The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury? A. Flushed lower body B. Pale and cool lower extremities C. Low blood pressure D. Absent reflexes

Nutritional consideration for the burn patient begins at which point in the continuum of care? a. Upon discharge b. Admission to burn unit c. After surgery d. Secondary survey in the trauma nurse process

Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent: a. catheter-associated infection. b. venous thromboembolism. c. fat embolism. d. nosocomial pneumonia.

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a.Administer acetaminophen as ordered for the headache. b.Assess for a kinked urinary catheter and assess for bowel impaction. c.Encourage the patient to take slow, deep breaths. d.Notify the physician of the patients blood pressure.

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is : a.Keeping the extremity in a dependent position b.Active and passive range of motion every hour. c.Preparing for an escharotomy as a prophylactic measure d.Splinting the forearm

The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan? A. Have chimneys swept every 2 years. B. Keep a smoke detector in each bedroom. C. Use space heaters instead of gas heaters. D. Use carbon monoxide detectors only in the garage.

The patient is being transported to the ER after a Motor Vehicle Collision. The patient's chin is tucked into the C spine collar. What is the next action by the nurse? a. readjust the collar b. evaluate the collar for proper size and fit c. intubate the patient d. remove the collar

The patient is brought to the ER with EMS. Fall on ice. The left leg is externally rotated and shorter than right. The patient has pelvic movement. The physician wants the patient to be logged roll to evaluate the posterior side. What is the best response from the nurse? a. Log rolling is not appropriate for this patient because of manipulation of the spinal cord. b. The patient has movement on pelvic exam. We need to stabilize the pelvis before moving. c. The patient has movement on pelvic exam. You will kill the patient. d. The patient has an obvious pelvic fracture. We will not be moving the patient.

The patient is enroute to the hospital with a Zone I injury to the neck/chest area. The nurse understands the significance of this injury because: a. This zone contains many great blood vessels that are life threatening if torn b. This zone contains first rib fractures are known sign of life threatening injuries because of the force needed to fracture c. This zone contains the cricoid cartilage and is life threatening when damaged d. This zone contains the heart and a blunt force could lead to ventricular rupture

The patient that arrived to the ER has obvious signs of inhalation injury with singed facial hair, strained voice, and burns to lips. What is the next step in treatment? a. Use an adjunct airway and continue to breathing assessment b. Requires definitive airway - intubate patient c. Apply non rebreather mask at 15L and move to breathing d. Reassess alertness of the patient

The wounded victim is unable to walk, has respiratory rate of 12, capillary refill is 8 seconds, and is unresponsive. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

The wounded victim is unable to walk, respiratory rate is absent but when airway is repositioned breathing is noted. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a.Carbon monoxide poisoning always occurs when soot is visible. b.Inhalation injury above the glottis may cause significant edema that obstructs the airway. c.The patient will have a copious amount of mucus that will need to be suctioned. d.The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

When would the consideration of transferring the patient to a different facility occur? a. At the end of the secondary survey b. At end of the primary survey and before starting the secondary survey c. During the airway and alertness phase d. At the across the room observation

Which is the most frequently diagnosed among trauma patients? a. Pneumothorax b. Rib fractures c. Sternal fractures d. Gunshot wounds

Which of the following statements about mass casualty triage during a disaster is true? a. Priority treatments and interventions focus primarily on young victims. b. Disaster victims with the greatest chances for survival receive priority for treatment. c. Once interventions have been initiated, healthcare providers cannot stop the treatment of disaster victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.

Which patient below is at MOST risk for developing a condition called autonomic dysreflexia? A. A 24-year-old male patient with a traumatic brain injury. B. A 15-year-old female patient with a spinal cord injury at C7. C. A 35-year-old male patient with a spinal cord injury at L6. D. A 42-year-old male patient recovering from a hemorrhagic stroke.

Which statement is CORRECT about a tension pneumothorax? A. This condition happens when an opening to the intrapleural space creates a two-way valve which causes pressure to build up in the space leading to shifting of the mediastinum. B. A tension pneumothorax is a medical emergency and is treated with needle decompression. C. Tracheal deviation is an early sign of a tension pneumothorax D. An open pneumothorax is the only cause of a tension pneumothorax.

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."

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.

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)

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."

for the care of this fracture, you need to elevate HOB to 40 degrees a. basilar skull fracture b. maxillary fracture

fracture goes through the entire thickness of the skull a. linear fracture b. no displaced fracture c. depressed skull fracture d. basilar skull fracture

resolution of acute phase of the disaster a. preparedness b. recovery c. mitigation d. response

which of the following is a cause of autonomic dysreflexia? a. eating too fast b. kinked catheter c. lying flat d. standing up too fast

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action?a.Keep the neck in the hyperextended position. b.Maintain proper head and neck alignment. c.Prepare for immediate endotracheal intubation. d.Remove cervical collar upon arrival to the ED

b - Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patients airway is compromised. The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.

A 15-year-old male client arrives at the emergency department. He is conscious, coherent, and ambulatory, but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? A. "The stick was really dirty and covered with mud." B. "He pulled the stick out, just now, because it was hurting him." C. "He's a diabetic, so he needs attention right away." D. "There was a lot of blood and we used three bandages."

b - An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss, depth of penetration, and medical history should be obtained.

The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client? A. Current range of motion in all extremities B. Heart rate and rhythm C. Respiratory rate and pulse oximetry reading D. Orientation to time, place, and person

b - Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes.

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a.Maintain body temperature. b.Monitor blood pressure. c.Pad all bony prominences. d.Use proper hand washing.

b - Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.

During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent: a. disseminated intravascular coagulation. b. multisystem organ dysfunction. c. septic shock. d. wound infection.

b - Patients with multisystem injuries are at high risk of developing myriad complications associated with the overwhelming stressors of the injury, prolonged immobility, and consequences of inadequate tissue perfusion and oxygenation. Maintaining effective tissue perfusion, oxygenation, and nutritional support are all vital to prevent progression into multiple organ dysfunction syndrome. Disseminated intravascular coagulation, septic shock, and wound infections are best prevented by addressing infection early and aggressively with appropriate antibiotics and nursing interventions to reduce infection (e.g. hand hygiene).

The nurse is performing the Trauma Nurse Process on a patient with a gunshot wound to the chest. The nurse hears a whistling noise. What is the next action by the nurse? a. Assess the chest for wound and cover with a nonporous dressing on 3 sides b. Assess the chest for wound and prepare for chest tube c. Assess the lung sounds for decreased on the affected side and prepare for a chest tube d. Assess the airway for stridor and prepare to intubate

The patient arrives to the ER with a Glascow Comma Score (GCS) of 15. Upon reassessment, the patient is responding to painful stimuli, has incomprehensible sounds, and flexes to withdrawal from painful stimuli. What would be the new Glascow Comma Score (GCS)? a. 8 b. 3 c. 14 d. 10

The patient is brought to the ER after a high speed collision. The patient is complaining of severe ABD pain and left shoulder pain. The nurse listens to the lung sounds and hears a gurgling like noise on the Left side. What would be the next action of the nurse? a. Notify the team of bowel sounds noted in the lung field and need to prepare for surgery for possible ruptured diaphragm b. Notify the team of absent lung sounds and prepare for intubation c. Notify the team of absent lung sounds and prepare for a chest tube for a tension pneumothorax d. Notify the team of a possible diaphragm rupture

What is the BEST position for a patient experiencing autonomic dysreflexia? A. High Fowler's with legs lowered B. Low Fowler's with legs lowered C. Semi-Fowler's with legs at heart level D. Prone

What is the safest way to move a patient with a possible spinal cord injury? a. 6 person lift b. with a sheet c. long board d. Log roll

Which is not a treatment for neurogenic shock? a. Adenosine b. Vasopressors c. IV isotonic fluids d. Atropine

Which statement below is INCORRECT about the yellow triage tag color in regards to a disaster situation? A. A survivor with this tag color is seen after patients with the green tag color. B. A survivor with this tag color can have treatment delayed for an hour or less. C. A survivor with this tag color has serious injuries that could eventually lead to the compromise of breathing, circulation, or mental status, especially if treatment is delayed more than an hour or so. D. A survivor with this tag color has second priority for treatment of injuries.

The family member of a patient with C2 injury asks the nurse when the patient will be extubated. Which of the following is the nurse's best response to the family member? a. The patient has a high thoracic spine injury and the team will extubate as soon as we can b. It is up to the patient when they can breathe on their ownThis is a high level injury. c. The patient needs to have a tracheostomy, PEG tube and be moved to a long term facility d. The patient has a high Cervical spine cord injury. With this type of injury requires long term ventilatory support.

The family of a client who has been burned asks at what point the client will no longer be at greater risk for infection. What is the nurse's best response? A. "As soon as he finishes his antibiotic prescription." B. "As soon as his albumin level returns to normal." C. "When fluid remobilization has started." D. "When the burn wounds are closed."

The most common cause of blunt force trauma? a. Stabbings b. Gunshot wounds c. Falls d. Motor Vehicle Collisions (MVC)

The nurse assesses the MVC patient and observes ecchymosis around both eyes, fluid dripping out of the nose and ears. The nurse notes these assessments are from which potential cause? a. Linear skull fracture b. Depressed skull fracture c. Le Fort III fracture d. Basilar skull fracture

The nurse is assessing a patient with a chest tube. The nurse palpates fine crackling above the chest tube insertion site. What is the next action by the nurse? a. Clamp the chest tube b. Call a Medical Response/Rapid Response c. Change the chest tube dressing d. Circle and time the area

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a.Stimulate the patient hourly. b.Continue to monitor the patient. c.Elevate the head of the bed d.Notify the physician immediately.

The nurse is caring for a patient with a known C2 injury. The family member comes out to tell the nurse the patient has a severe headache, perfuse diaphoresis and flushing. What is the next action by the nurse? a. Get some Acetaminophen for the headache b. Evaluate the patient for an intracranial bleed c. Evaluate the patient for an MI d. Evaluate the patient for issues with bladder, bowel and or skin

The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first? A. Applies silver sulfadiazine (Silvadene) ointment B. Covers the area with an elastic wrap C. Places a synthetic dressing over the area D. Removes loose nonviable tissue

The patient arrives to the ER via EMS with large neck laceration. With the across the room observation, the nurse notes pulsatile bleeding. The next action for the nurse to take is? a. Assess the alertness b. Assess airway c. Assess breathing d. Start the MARCH mnemonic

The patient arrives with a family member found in a garage with a car running. The patient is place on the monitor, the SpO2 is 100%. The patient is lethargic, cyanotic with shallow respirations at 26/min. What is the next action by the nurse? a. Place an EtCO2 monitor on the patient b. Place the patient on nasal cannula at 2L c. Obtain a stat ABG d. Place the patient on 15L Non Rebreather mask

The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

The patient is a possible spinal cord injury from a skiing accident. The following are the patient's vital signs. Temp 98.0, HR 130, B/P 78/50. The patient was intubated at the scene by paramedics. What is the next action by the nurse in regards to the vital signs? a. Start the neurogenic shock protocol and give atropine b. Assess the Glascow Comma Score c. Assess the airway d. Look for signs of bleeding

The patient returns from the OR for an ORIF of the left femur from a MVC. The patient is very restless, tachypneic, tachycardic, lethargic, and a petechiae rash to the chest. The nurse hypothesizes which of the following conditions is occurring? a. Capillary Leak Syndrome b. Compartment Syndrome c. Retroperitoneal Bleed d. Fat Emboli Syndrome

The patient with the asymmetrical chest movement after a Motor Vehicle Collison (MVC) with an EtCO2 of 55. What is the next action of the nurse and rationale? a. Prepare for a chest tube. The patient has a possible pneumothorax b. Prepare for a chest tube. The patient has a possible hemothorax c. Prepare for intubation. The patient has a possible flail chest and ineffective respirations d. Prepare for intubation. The patient has a possible flail chest and ineffective ventilation

The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

Which type of burn is at high risk for Rhabdomyolysis? a. Thermal b. Radiation c. Chemical d. Electrical

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak.

elements of warning/evacuation, rescue, triage of victims, aiding victims, damage assessment, actions to support infrastructure a. preparedness b. recovery c. mitigation d. response

fracture of any of the 5 bones at the base of the skull a. linear fracture b. no displaced fracture c. depressed skull fracture d. basilar skull fracture

what is the best practice for eliciting the pain response? (Select all that apply) a. Tapping the shoulders b. Sternal rub c. Taking a sharp object across the feet d. Pinching axillary folds e. Nailbed pressure

d and e

Prevention of hypothermia is crucial in caring for trauma patients. The correct order of actions for the preparation for the trauma patient is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.) a. Remove wet clothing. b. Warm fluids and blood products before administration. c. Cover the patient with an external warming device. d. Warm the ED or intensive care unit (ICU) room before the patient's arrival.

d, a, c, b

Grey Turner's sign

discoloration over the flanks suggesting intra-abdominal bleeding.

A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in the house. What is the priority action? A. Instruct personnel to don personal protective equipment B. Direct the clients to the cold or clean zone for immediate treatment C. Immediately remove other clients and visitors from the area D. Measure vital signs and auscultate lung sounds E. Direct the clients to the decontamination area

what does soft sign mean?

easier to put pressure on and control - can lead to a hard sign

what does primary survey for E include?

environment and exposure - we remove all remaining clothing, inspect other areas for s/s of bleeding and keep the patient WARM

when checking pupils for a skull fracture how should they be ?

equal and reactive to light - if they are greater than a millimeter difference of unequal pupils you should be concerend

ARDS is a complication due to what

excessive inflammation and over-resuscitation.

t/f: blood tubing has air vents

false

what is this? blocking of small blood vessels by fat globules subsequent to a fracture, especially one of long bones or pelvis

fat emboli syndrome

a patient presents with a change in LOC, severe respiratory distress, petechiae rash on the eyes and chest with thrombocytopenia. what do you suspect is occurring and how do we treat?

fat emboli syndrome! - give o2 and admin albumin IV

what are the central pulse locations?

femoral and carotid

what is capillary leak syndrome with burns?

fluid shifts into the 3rd space due to release of mediators that contribute to the permeability of capillary membrane and allows plasma to pass through leaving RBC behind

during the secondary assessment of the trauma patient what can the family also provide with SAMPLE?

further info and history on the patient ! S: s/s of injury A: allergies M: medications especially anticoagulants or anti platelets that may be making bleeding worse P: pmh L: last oral intake E: events leading up

what does primary survey for L include?

get labs like ABG, VBG, lactic acid

what does primary survey for G include?

get monitoring devices and comfort the patient - consider LMNOP

how do we treat open fractures no matter what?

giving a tetanus shot and antibiotics

what are the most common penetrating traumas?

gunshots and stabs

how do we test if it is CSF coming out of the nose or ear with a basilar fracture?

halo test - place sheet under patient and catch a drop - if it is CSF: white ring outside and blood on the inside

what is the issue with the glasgow scale with patients that are intubated or aphasic and how do we get around this?

hard for them to speak verbally to us, so we should ask them to "show us 2 fingers" to see if they respond to verbal commands

what is the leading cause of preventable death

hemmoragaing

how do you care for a mangled extremity ?

hemmorage control with a tourniquet is our number one priority !!! - we also would wound manage and possible amputation

do solid or hollow organs leak more and cause infections

hollow

what is an example of mass causality event

hurricane

what pressure is this? force exerted by fluid pressing against the wall divided into capillary and tissue pressures

hydrostatic pressures

a patient presents with N/v, neuro impairment, abnormally low blood pressure and flushing. what do you expect is going on ?

hyper magnesia

a patient presents with Abdominal (belly) pain and diarrhea, Chest pain, heart palpitations and muscle weakness. what electrolyte imbalance do you expect?

hyperkalemia

a patient presents with abnormally high blood pressure, asthma, irregular heart beat and weak bones. what do you expect is going on

hypo magnesia

a patient presents with weakness, fatigue, muscle cramps and palpitations. what do you expect is going on?

hypokalemia

when treating a patient for a pelvic fracture, after we do the primary assessment what is a key consideration ?

if we need to transfer them to a #1 trauma center due to the risk of bleeding out from big vessels being damaged

is this a complete or incomplete lesion? can lead to other syndromes

incomplete

is this a complete or incomplete lesion? spares some motor function below the level of injury

incomplete

what is the purpose of debriefing after a mass causality event or incident?

it helps staff talk about what are the lessons learned coming out of this and where can we improve and how were our resources?

what is the purpose of a MESS SCORE?

it is used for mangled extremities to see if we can salvage any of the limbs or if they just need to be amptutated

what is the function of the wet system chest tube

it uses a water seal and water column regulator and suction pressure is regulated by the height of the column in the suction control chamber

a patient presents with hematuria, flank tenderness and costovertabreal angle tenderness. what do you suspect?

kidney injury or kidney bleed

what are the potential problems if a neuro spine patients that have been bed ridden and are concerned with their skin?

look for risk of skin breakdown, look if they are developing contractors, infection, sepsis, autonomic dysreflexia

during the secondary assessment of the trauma patient, what does looking at MIST include?

looks at the report of injury M: mechanism of injury I: injury sustained S: S/S in field T: treatment provided in the field

what is the dry system chest tube

mechanically regulates suction pressure with a dial that goes to 40 cm

what does primary survey for M include?

monitor cardiac r/r and compare pulse to monitor

do we need a c spine? patient is alert and oriented with no neuro issues

what pressure is this? The pressure of water to move, typically into the capillary, as the result of the presence of plasma proteins.

oncotic pressure

what are impacted fractures?

one fragment pushed into another

what does primary survey for O include?

oxygenation and ventilation assed with SPO2 and ETCO2

what does hard sign mean?

places hard to hold pressure onto and can you ASAP

what part of the initial assessment is this? the trauma team is notified of the patient and finds out the ETA of the patient

preparation

what is the purpose of the suction control chamber for the chest tube

pressure applied to suction in order to remove air and fluid from pleural cavity. Sterile water placed in chamber to 20 cm line or prescribed amount. Turn on wall vacuum until slow gentle continuous bubbling.

what is this? due to bruise on the lung that leads to fluid and edema in the lungs and leads to hypoxia

pulmonary contusion

where are the peripheral pulses located

radial and tibial

Kehr sign is defined as:

referred pain to the shoulder following injury to the liver or spleen.

what is the golden hour?

refers to the first hour after an injury trauma deaths in this time can be reduced by prompt initial care in the pre-hospital phase, by early hospital resuscitation, and by prompt/competent definitive care management at this time will affect the third peak of deaths (days-weeks post-injury)

what is this? exchange of gases across a membrane between the lungs and blood or blood and tissues

respirations

what is this? assure the patient gets right hospital in right amount of time

safe care

what is this? protect the trauma team with PPE prior to the patients arrival

safe practice

do solid or hollow organs bleed more

solid

if we suspect a neuro injury what is the first step to do?

stabilize the spinal cord until it can be ruled out

if the patient is able to talk, what does that confirm in the primary survey?

that the patient has an airway

how do we take care of capillary leak syndrome with burns?

the capillaries will start to repair itself if you support them with nutrition, monitor HCT and look at ratio with plasma and RBC

if the patient is moaning, what does that confirm in the primary survey

the patient has an airway but needs to test alertness due to maintaining an airway and make sure that they dont choke

why are we concerned if a patient has a babinski reflex present?

they are going back to primitive reflexes that should have gone away - shows issue with brain

what are the potential problems if a neuro spine patients that have a loss of vasomotor tone and paralysis ?

they can go into neuro shock - monitor their HR - look for DVT

what are the potential problems if a neuro spine patients that have c spine compression and edema

they can lose sensory and motor loss below level of injury with ischemia

what is the purpose of the collection chambers for the chest tube?

they collect either air or blood that is coming from the patient

dark red or pink tinged urine output with a burn patient indicates what? how do we resolve this?

this indicates that they are excreted myoglobin ! - we need to increase the fluid and continue to flush out the kidneys

if you give pain medications to a patient and come back to re asses their pain and its the same or worse, what should you be thinking?

this is a sign of worsening cellular hypoxia and you should think they are starting to develop compartment syndrome - will want to take off a cast if one is on

if your Patient's needs outweigh your facilities capabilities, what should you do?

transfer the patient to a better trauma center

what trauma hospital provides the highest level of surgical care for trauma patients

trauma center 1

what is this? sorting of patients based on their needs and treating most life threatening patients as priority

triage

t/f: a mass causality event or incident requires coordinated response efforts at all level

true

t/f: all trauma patients receive a tetanus shot

true

t/f: bright red lips and tachycardia are present in carbon monoxide poisoning as well.

true

t/f: it takes a lot of force to break the skull

true

t/f: large wounds can take months to full heal

true

t/f: while inspecting the environment, clothing can be used as evidence for bleeding so we should place it in a brown bag

true

t/f: you need to encourage every person to have a co2 detectors in every room, every floor and every house

true

what is the leading cause of death?

unintentional injuries

what is this? active movement of air in and out of lungs with inspiration and expiration

ventilation

what are the potential problems if a neuro spine patients with GI/Gu bladder losses that need to be cathed and meds for bowel?

we need to institute feeding and bowerl regime

if the patient present with a headache, blurred vision and less alert then when they came into the trauma center, how do we position the patient and why?

we place them in reverse trendelenburg to decrease pressure and swelling in the brain

when would we do an emergent fasciotomoy?

with any pressure greater than 30 you would cut the skin to relieve the pressure

what are indications that a chest tube is needed?

- pneumothorax - tension pneumothorax - hemothorax - pleural effusion - emphysema - cardiac surgery

what are examples of soft signs?

- small stable hematoma - failure of cranial nerve - unclear neuro deficit - hoarseness - sublet emphysema - difficult swallowing - mild hemoptysis

if the patient is breathing, how do we proceed?

- support and maintain with 10-15 l - asses ventilation with ETCO2 -asses oxygenation with SPO2

what is the purpose of the water seal chamber for the chest tube

- where pressure equals out to allow the lung to equal out - chest tube chamber that provides a one-way valve so that air leaves and cannot reenter chest - bubbling is normal initial 48 to 72 hours - tidaling (expected to rise with inspiration, fall with exhalation)

from burns, hypermetabolism lead to significant skeletal muscle breakdown with protein degradation will delay all body responses including what?

- wound healing - immune system

what do we asses when doing the jaw thrust maneuver on the patient

- if tongue or teeth is obstructing the airway - any blood, vomit, burns - listen to airway - palpate face for any deformities or bubbles

what are the cons to dry system chest tube

- does not provide same level of patient assessment info as wet system

pro to wet system chest tube

- easy set up - cheap

what are roles of the trauma nurse?

- effective communication - delivery of timely care - serial assessment - make good choices - anti-cite priorities - maintain order - delegate roles - demonstrate resiliency

what does primary survey for F include?

- full set of vitals and note trends q 15 mins - with the family educate on whats going on with the patient, support the patient and the family

what are examples of hard signs?

- hemmorage shock - expanding hematoma - active bleeding - airway obstruction - air discharge from you d - hemophysia - active pulsatile flow

what are the pros to dry system chest tube

- higher suction - quiet operation - no fluid evaporation

what are labs that we take with a spinal injury or injury to the nervous system?

- CBC/CMP - type and cross - CXR - ABG - NGT - CT - MRI

what labs do we need to monitor with compartment syndrome?

- CK - CPK - myoglobin - K - CR

what are causes of spinal alterations?

- MVC - falls - violence - sports - lifting - arthritis - diving

what are the key interventions for open fractures

- admin tetanus and antibiotics - remove gross contaminates - cover with sterile saline soaked in dressing

what are conditions act require and ET TUBE ASAP

- apnea - GCS < 8 - severe facial fractures - neck hematoma - injury or burn to mouth - compromised ventilation - suspected decline in LOC that would effect ability to keep airway open

con to wet system chest tube

- can tip/spill - sterile water must be added several times a day to maintain suction and water seal

how do we treat amputations?

- direct pressure over active bleeding site with elevation of extremity * if this doesnt work you would use a tourniquet - remove debris and dirt from the limb - give tetanus shot and antibiotics

what is the best Glasgow scale score you can achieve

A patient has a chest tube for treatment of a pneumothorax in the left lung. Which finding during your assessment requires immediate nursing intervention? A. The water seal chamber has intermittent bubbling. B. The patient has slight tracheal deviation to the right side. C. The water seal chamber fluctuates while the patient inhales and exhales. D. The patient complains of tenderness at the chest tube insertion site.

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a.Central nervous system deficits b.Contractures c.Infection d.Stress ulcers

During the circulation phase of the trauma nurse process, the nurse should initiate _______ solution at ___________mL/hr. a. 3% saline at 500 mL/hr b. NS at 500 mL/hr c. D5W at 500 mL/hr d. LR at 500 mL/hr

what do we monitor with capillary leak syndrome with burns?

HCT - we want to make sure to keep HCT high due to hemodilution

which trauma chart is more specific to age and size with proper burn %

Lund and Browder Chart

what does primary survey for N include?

NGT or OGT considered

On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action? A. Documenting the findings B. Loosening any dressings on the chest C. Raising the head of the bed D. Preparing for intubation

what are the potential problems if a neuro spine patients need a ventilator for injury to the diaphragm ?

VAP RISK - so oral care and prophylaxis is important

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? A. Drainage of a clear fluid from the client's nose B. Withdrawal of the client in response to painful stimuli C. Bruises and minimal edema of the eyelids D. Bleeding around the lacerations

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? A. Begin intravenous fluids. B. Check the pulses with a Doppler device. C. Obtain a complete blood count (CBC). D. Obtain an electrocardiogram (ECG).

A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a: A. 1st degree (superficial) burn B. 2nd degree (partial-thickness) burn C. 3rd degree (full-thickness) burn D. 4th degree (deep full-thickness) burn

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? A. Intermittent bubbling may be noted in the water seal chamber. B. 200 cc of drainage per hour is expected during recovery of a pneumothorax. C. The chest tube is positioned at the patient's chest level to facilitate drainage. D. All of these options are appropriate findings.

An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a. Level I b. Level II c. Level III d. Level IV

During the assessment of airway and alertness, the nurse identifies that the patient is unresponsive. What is the next action by the nurse? a. Announce loudly to the team b. Move to assess the mouth for any obstructions c. Remove the C collar d. Begin chest compressions

Nurse Kelly, a triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority? A. Administer oxygen therapy via nasal cannula B. Notify the physician C. Complete history taking D. Put the client on ECG monitoring

Ten hours after the client with 50% burns is admitted, her blood glucose level is 140 mg/dL. What is the nurse's best action? A. Documents the finding B. Obtains a family history of diabetes C. Repeats the glucose measurement D. Stop IV fluids containing dextrose

The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a "small amount of pain." How will the nurse categorize this injury? A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Superficial

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patients plan of care? a.Frequent neurological assessments b.Side to side position changes c.Range of motion to extremities d.Frequent oropharyngeal suctioning

The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a.Monitor the patients airway patency. b.Elevate the head of the patients bed. c.Increase supplemental oxygen delivery. d.Support bony prominences with padding.

the nurse completed the secondary survey with a patient that has a skull fracture. The nurse performs the following interventions: (select all that apply) a. HOB > 30 degrees b. Remove the C collar c. Pack the nose and ears d. Caution the patient not to blow nose e. Monitor for LOC/GCS changes

a, d, e

Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a. A fall from a 6-foot ladder onto the grass b. A shotgun wound to the abdomen c. A knife wound to the right chest d. A motor vehicle crash in which the driver hits the steering wheel

b - The penetrating injury of the gunshot wound would cause the greatest amount of injury because of the kinetic energy and dispersion pattern of the shotgun ammunition once it penetrated the body. A fall would cause a compression injury from the blunt force of the fall. The knife wound would cause a penetrating injury in which the magnitude of the injury would depend on damage to the vessels and lung. Blunt chest trauma that may include a cardiac contusion is possible following an injury in which the patient hits the steering column.

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 - think of TBSA

Fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully cross-matched blood products are administered.

b and c - Lactated Ringer's and normal saline are the crystalloids of choice in trauma resuscitation. Because hypothermia is a concern, fluids should be warmed. Massive blood transfusions are associated with poor outcomes. Cross-matched blood is preferred, but blood type O, universal donor blood, can be administered in an emergency.

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 and c - 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.

Which statements are TRUE about autonomic dysreflexia? Select all that apply: A. "Autonomic dysreflexia is an exaggerated reflex response by the parasympathetic nervous system that results in severe hypertension due to a spinal cord injury." B. "Autonomic dysreflexia causes a slow heart rate and severe hypertension." C. "Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury." D. "The first-line of treatment for autonomic dysreflexia is an antihypertensive medication."

b and c - it occurs in the sympathetic nervous system - Option D is false because medications are used only if the blood pressure is not decreasing or the cause cannot be determined.

You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the in-service: A. Hypoglycemia B. Distended bladder C. Sacral pressure injury D. Fecal impaction E. Urinary tract infection

b, ,c ,d e

It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. ARDS b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction

b, c, d

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.

b, c, d, e

The patient is identified in the across the room observation to have massive external hemorrhage to the lower legs: What is the next action by the trauma team? Select all that apply. a. Obtain laboratory studies b. Restorative resuscitation with 1:1:1 ratio c. Assess neurological status d. Achieve SBP 80-90 mm Hg ASAP e. Tourniquets f. Place on ventilator

b, d, e

The client who is burned is drooling and having difficulty swallowing. Which action will the nurse take first? A. Assesses level of consciousness and pupillary reactions B. Ascertains the time food or liquid was last consumed C. Auscultates breath sounds over the trachea and mainstem bronchi D. Measures abdominal girth and auscultates bowel sounds

The nurse notes that a general intervention(s) on abdominal/pelvic trauma patients include: (select all that apply) a. Serial LFTs b. MARCH mnemonic c. Amylase/lipase d. Giving 1 liter of crystalloid solution e. Insertion of urinary catheter f. Operative management

d and e

why is c spine the worst place for a spinal injury?

because it can cause paralysis and injure the diaphragm from being able to breathe

why dont we asses the airway with a head tilt chin lift maneuver?

because it can disrupt the c spine and cause further damage or cause paralysis

why do we worry about le fort 2 and 3 for maxillary fractures?

because of airway and massive facial edema that may compromise the airway

why do you need to take patients who have had a ruptured diaphragm to the OR immediately

because the GI contents are in the lung area making it harder to breath and you need to fix the diaphragm and move bowel contents down

if a patient has a bunch of chest abrasions why would we probably hook them up to oxygen?

because they will most likely have a pulmonary contusion that starts out vauge and sooner or later become hypoxic

why are femur and pelvic fractures more on the fatal side

because you can lose up to 30-40% of your blood

why can pulmonary contusions lead to pneumonia

because you have fluid that sits in your lung and cant get out

we have to keep the MAP above what for spinal injuries and why?

between 85-90 to prevent 2nd injury to spinal cord

Cullen sign

bruising around umbilicus showing intraperitoneal bleed

A 23-year-old male client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? A. How to maintain home smoke detectors B. Joining a community reintegration program C. Learning to perform dressing changes D. Options available for scar removal

A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED: a. includes a cervical spine x-ray study to determine the presence of a fracture. b. involves turning the patient from side to side to get a look at his back c. is done quickly in the first few minutes to get a baseline assessment and establish priorities. d. is a methodical head-to-toe assessment identifying injuries and treatment priorities.

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor? A. Red B. Yellow C. Green D. Black

A hurricane is expected to hit Virginia, the hospital sets up a disaster plan for which type of event? a. Part of the preparedness cycle b. Part of the mitigation cycle c. Mass Causality Event d. Mass Causality Incident

A new nurse is orienting to the ER. The preceptor is preparing the new nurse for a patient arriving from a motor vehicle collision (MVC). Which of the following responses from the new nurse would the preceptor have to correct? a. I will assess airway and alertness using the AVPU mnemonic b. I will check the room for equipment that may be needed and it is functioning c. I will use the tilt chin lift maneuver to open the airway d. I will keep the patient warm by increasing the room temperature

A patient arrives to the ER after being involved in a violent crime, the nurse should handle the clothing by: a. Throwing them on the floor and clean up later b. Give the clothing to the family c. Place in bag that can be used as evidence d. Throw the clothing away

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

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

Calculate the percentage of total body surface area (TBSA) using the rule of nines - Right leg anterior and posterior and total abdomen anterior and posterior. a. 28% b. 42% c. 36% d. 18%

In regards to ta open pneumothorax, which of the following options below is a nursing intervention you would provide to this patient? A. Place the patient in supine position B. Place a non-occlusive dressing over the chest wound C. Place a sterile occlusive dressing over the chest wound and tape it on three sides D. Prepare the patient for a thoracentesis

In the trauma patient, symptoms of decreased cardiac output are most commonly caused by: a. cardiac contusion. b. cardiogenic shock. c. hypovolemia. d. pericardial tamponade.

What is included in the secondary survey? Select all that apply a. Assessing the need to transfer to another facility b. Obtaining laboratory value c. Wound care d. Obtain a history e. Head to toe assessment

d and e

Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a. A patient who has a closed head injury with a decreased level of consciousness b. A patient who has a fractured femur and is currently in traction c. A patient who has received large volumes of fluid and/or blood replacement d. A patient who has underlying chronic obstructive pulmonary disease

c - During states of hypoperfusion and acidosis, inflammation occurs and vessels become more permeable to fluid and molecules. With aggressive fluid resuscitation, this change in permeability allows the movement of fluid from the intravascular space into the interstitial spaces (third spacing). As more IV fluids are given to support systemic circulation, fluids continue to migrate into the interstitial space, causing excessive edema and predisposing the patient to additional complications such as abdominal compartment syndrome, ARDS, acute kidney injury, and MODS. A patient with a closed head injury, a patient with a fractured femur stabilized by traction, and a patient with chronic obstructive pulmonary disease may develop ARDS, but it would be related to fluid resuscitation and excessive inflammation associated with traumatic injury.

A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can't move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to? A. Red B. Black C. Yellow D. Green

c - The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is Yellow.

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is: a.blood urea nitrogen. b.daily weight. c.hourly intake and urine output. d.serum potassium.

c - during initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone

You're performing a head-to-toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient's blood pressure and heart rate. The patient's blood pressure is 140/98 and heart rate is 52. You look at the patient's chart and find that their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take FIRST? A. Reassess the patient's blood pressure. B. Check the patient's blood glucose. C. Position the patient at 90 degrees and lower the legs. D. Provide cooling blankets for the patient.

c - this can help pool the extremities with blood and decrease blood pressure

What are the best practices in assessing ventilatory status in a patient? Select all that apply a. Symmetrical rise and fall of chest b. Capillary refill c. Respiratory depth and rate d. EtCO2 e. SpO2

c and d

The correct order of actions in the management of the postoperative surgical trauma patient who has been admitted to the critical care unit after surgery is: _______________, _______________, _______________,_______________. (Put a comma and space between each answer choice.) a. Connect the patient to bedside monitor and mechanical ventilator. b. Obtain vital signs, rhythm, oxygen saturation, and neurological status. c. Assess airway, breathing, and circulation. d. Reassess and evaluate patency of IV lines, and adjust rate of fluid administration as ordered.

c, a, b, d

Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a. Absence of pulse in affected extremity b. Pallor in the affected area c. Paresthesia in the affected area d. Severe, throbbing pain in the affected area

An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do first? A. Provide oxygen therapy B. Notify the physician immediately C. Administer anxiolytic medication as ordered D. Have the client breathe into a brown paper bag

what is this? involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles

compartment syndrome

a patient presents with weak pulses, paresthesia and burning in their leg. what do you suspect is going on and what is the treatment?

compartment syndrome is occurring! - we would remove the cast, elevate the limb to the level of the heart, give IV fluids of crystalloids ASAP to maintain a urine output of 100 ml/hr to get the kidneys perfusing

is this a complete or incomplete lesion? it is permanent

complete

is this a complete or incomplete lesion? motor and sensory function is lost with intact bulbo reflex

complete

how is the airway adjunct measured?

corner of ear to corner of mouth

A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following? A. "How long ago did the incident occur?" B. "What was the initial first aid done?" C. "Where did the incident happen?" D. "What direction did the bullet enter into the body?"

A 40-year-old male client who was burned was admitted under your care. Assessment reveals he has crackles, respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first? A. Administer digoxin B. Perform chest physiotherapy C. Monitor urine output D. Place the client in an upright position

A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury? A. Redness and bruising may indicate the site of the injury in blunt trauma B. The client is symptom-free during the early post-injury period C. Signs of peritoneal irritation may indicate pancreatic injury D. All of the above

A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side, and there is a large crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

Across the room observation is to identify life threatening conditions. Which type of patient would exhibit life threatening conditions upon arrival that can cause death within minutes? a. 35 y/o alert patient with multiple abrasions on the legs that are oozing b. 82 y/o confused patient with ecchymosis to the chin area c. 50 y/o alert patient with a tourniquet to the left leg above the knee d. 26 y/o unresponsive patient with an femoral artery bleed

After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? a.A patient with meningitis complaining of photophobia b.A mechanically ventilated patient with a GCS of 6 c.A patient with bacterial meningitis on droplet precautions d.A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F

After taking all the necessary steps for a patient who has developed autonomic dysreflexia, what should the nurse assess FIRST as a possible cause of this condition? A. Skin break down B. Blood glucose C. Possible bladder irritant D. Last bowel movement

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102 F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a.Ensure adequate periods of rest between nursing interventions. b.Insert an oral airway and monitor respiratory rate and depth. c.Maintain neutral head alignment and avoid extreme hip flexion. d.Reduce ambient room temperature and administer antipyretics.

d - In this scenario, the patients temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.

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..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).

The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? a.Insert bilateral ear plugs. b.Monitor airway patency. c.Maintain neutral head position. d.Apply a small nasal drip pad.

d - Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.

The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels

d - Serum lactate levels are useful in assessing acidosis and the need for aggressive fluid resuscitation. Arterial oxygen saturation provides clinical information on oxygen delivery to cells. Hourly urine output and mean arterial pressure provide information on systemic perfusion and are monitored in the assessment of effective resuscitation; however, serum lactate is a better indicator of metabolic acidosis caused by under-perfusion (under-resuscitation)

Which of the following interventions is a strategy to prevent fat embolism syndrome? a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with low-molecular weight heparin. d. Stabilize extremity fractures early.

d - Stabilization of extremity fractures to minimize both bone movement and the release of fatty products from the bone marrow must be accomplished as early as possible.

While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned? A. Green B. Red C. Yellow D. Black

d - The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A. Unequal pupils B. Irregular pulse C. Ecchymosis in the flank area D. A deviated trachea

d - due to a tension pneumothorax

The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of his car. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates: a. administration of lactated Ringer's solution (1 L) wide open. b. chest x-ray study to determine the etiology of the symptoms. c. endotracheal intubation and mechanical ventilation. d. needle thoracostomy and chest tube insertion.

d - these are key signs of a tension pneumothorax. you would treat this first and then if it doesn't resolve we would intubate and ventilate

the nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because: a.intramuscular injections cause additional skin disruption. b.burn pain is so severe it requires relief by the fastest route available. c.hypermetabolism limits effectiveness of medications administered intramuscularly. d.tissue edema may interfere with drug absorption of injectable routes.

d -Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly. Even though it is true intramuscular injections disrupt tissue, medication absorption is not effective. Burn pain is severe and intravenous administration is desired to relieve pain, but this is not the physiological basis for giving medications intravenously. Hypermetabolism affects medication effectiveness but is not the rationale for administering opioids intravenously.

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 - the nurse cannot increase the fluids but that is what the physician will probably recommend

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