MS2 Final Exam Practice Questions - Ch. 9, 10, 12, 28

Which assessment does the nurse perform first on the client just admitted after an electrical injury with contact sites on the left hand and left foot? A. Core body temperature B. Electrocardiography C. Depth of burn injury D. Urine output

B. Electrocardiography Rationale B. With contact sites on the left hand and foot, the current traveled in all body tissues between these two areas, with the potential to damage any tissue in the pathway. The heart is in this pathway and can suffer extensive damage to the muscle and the conduction system. Continuous electrocardiography (ECG) monitoring to determine heart health is the most important of the assessment areas listed. Reference: p. 523, Physiological Integrity

During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Observe the patient's respiratory effort. b. Check the patient's level of consciousness. c. Palpate extremities for capillary refill time. d. Examine the patient for any external bleeding.

A Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions also are part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.

A patient who has experienced blunt abdominal trauma during a car accident is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. ultrasonography. b. peritoneal lavage. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).

A For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding.

A patient arrives in the emergency department (ED) a few hours after taking "20 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine (Mucomyst). b. Discuss the use of chelation therapy. c. Have the patient drink large amounts of water. d. Administer oxygen using a non-rebreather mask.

A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning.

34. A client who suffered burns in a house fire reports a headache and is not consistently oriented to time. Which intervention by the nurse is most appropriate? a. Increase the client's oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the client's intravenous fluid rate. d. Perform a thorough Mini-Mental Status Examination.

ANS: B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.

After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care? a. Rapidly infuse cold normal saline. b. Avoid the use of sedative medications. c. Check neurologic status every 30 minutes. d. Rewarm if temperature is >91° F (32.8° C).

A When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Since hypothermia will decrease brain activity, neurologic assessment every 30 minutes is not needed. Sedative medications are administered during therapeutic hypothermia.

36. Which statement made by the client who experienced burns to the head and neck indicates positive adjustment to the injury? A. "I am planning on cutting the grass in the mornings when the sun isn't as strong." B. "I am working with my family so they can do all of the chores I used to do." C. "I hope the home care nurse can change my dressings so that I do not have to look at my wounds." D. "My wife and I have decided to go to movies instead of baseball games so that people can't see me."

A. "I am planning on cutting the grass in the mornings when the sun isn't as strong." Rationale A. Reintegrating into the family situation and assuming the roles and responsibilities performed before the injury are positive signs of beginning successful adjustment. Reference: p. 539, Psychosocial Integrity

The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication? A. Furosemide (Lasix) B. Digoxin (Lanoxin) C. Dopamine (Inotropin) D. Morphine sulfate

A. Furosemide (Lasix) Rationale A. Furosemide, a diuretic, generally is not given to improve urine output for burn clients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs.

9. Which finding indicates to the nurse that a client understands the psychosocial impact of a severe burn injury? a. "It is normal to feel some depression." b. "I will go back to work immediately." c. "I will not feel anger about my situation." d. "Once I get home, things will be normal."

ANS: A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

30. The nurse has been teaching a client about skin grafting procedures. What statement indicates that the client needs further education about allografts? a. "Because the graft is my own skin, there is no chance it won't 'take.'" b. "For a few days after surgery, the donor sites will be painful." c. "I will have some scarring in the area where the skin is removed." d. "I am still at risk for infection after the procedure until the burn heals."

ANS: A Factors other than tissue type, such as circulation and infection, influence whether and how well a graft will work. The client should be prepared for the possibility that not all grafting procedures will be successful. Donor sites will be painful after surgery, scarring can occur in the area where skin is removed for grafting, and the client is still at risk for infection.

12. The hospital administration has arranged for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. "You are free to express your feelings; whatever is said here stays here." b. "Let's determine what we can do better the next time we have this situation." c. "This session is only for nursing and medical staff, not for ancillary personnel." d. "Let's pass around the written policy compliance form for everyone."

ANS: A Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

18. The nurse is triaging clients in the emergency department (ED). Which is true about the presentation of client symptoms? a. Older adults frequently have symptoms that are vague or less specific. b. Young adults present with nonspecific symptoms for serious illnesses. c. Diagnosing children's symptoms often keeps them in the ED longer. d. Symptoms of confusion always represent neurologic disorders.

ANS: A Older adults present with symptoms that often are different or less specific than those of younger adults. For example, increasing weakness, fatigue, and confusion may be the only admission concerns. These vague symptoms can be caused by serious illness, such as an acute myocardial infarction (MI), urinary tract infection, or pneumonia. Diagnosing older adults often keeps them in the ED for extended periods of time.

9. A client has been injured in a stabbing incident. Assessment reveals the following: Blood pressure: 80/60 mm Hg - Heart rate: 140 beats/min - Respiratory rate: 35 breaths/min - Bleeding from stabbing wound site - Client is lethargic Based on these assessment data, to which trauma center should the nurse ensure transport of the client? a. Level I b. Level II c. Level III d. Level IV

ANS: A The Level I trauma center is able to provide a full continuum of care for all client areas. Level II can provide care to most injured clients, but given the extent of his injuries, a Level I center would be better if it is available. Both Levels III and IV can stabilize major injuries, but transport to a higher-level center is preferred, when possible.

10. The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do first? a. Assess that the client is breathing adequately b. Insert a large-bore intravenous line c. Place the client on a cardiac monitor d. Assess for best neurologic response

ANS: A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he may not be breathing, or he may be breathing inadequately with the device in place.

3. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

ANS: A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fracture and the client with the head injury would be classified as urgent with red tags.

3. Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.) a. Removing wet clothing b. Splinting open fractures c. Initiating IV fluids d. Endotracheal intubation e. Foley catheterization f. Needle decompression g. Laceration repair

ANS: A, C, D, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: A, airway and cervical spine control; B, breathing; C, circulation; D, disability; and E, exposure. After completion of primary diagnostic studies and laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete head-to-toe assessment, can be carried out.

7. The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first? a. 22-year-old with a painful and swollen right wrist b. 45-year-old reporting chest pain and diaphoresis c. 60-year-old reporting difficulty swallowing and nausea d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F

ANS: B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

3. The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. What should the nurse do next? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.

ANS: B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

8. Which statement best exemplifies a client's understanding of rehabilitation after a full-thickness burn injury? a. "I am fully recovered when all the wounds are closed." b. "I will eventually be able to perform all my former activities." c. "My goal is to achieve the highest level of functioning that I can." d. "Full recovery from a major burn injury never occurs."

ANS: C Although a return to preburn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning.

35. A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide before 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

ANS: C Critical for the goal of progression toward independence for the client is teaching clients and family members to perform care tasks such as dressing changes. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.

15. The emergency department (ED) is expecting a large number of casualties after a bridge collapse. Which is a priority consideration for the ED leadership when activating the disaster plan? a. Responding paramedics and rescue personnel will notify the ED about exactly how many victims to expect. b. Responding paramedics and rescue personnel will triage all victims at the bridge collapse site before bringing them to the ED. c. The ED may receive many unexpected victims with minor injuries from the bridge collapse. d. Victims who have been contaminated with gasoline will be decontaminated by rescue personnel before arriving at the ED.

ANS: C Paramedics may not note all the "walking wounded" to give the ED an accurate count of victims to expect because these people might evacuate themselves from the accident scene without being seen by paramedics or rescue personnel. They may then secure their own transportation to the hospital and could overwhelm an ED that is already handling many severely injured victims who have been brought in by emergency medical services (EMS).

12. The nurse is providing care for a client admitted for suicidal precautions. What priority intervention should the nurse implement first? a. Administer prescribed anti-anxiety drugs. b. Decrease the noise level and the harsh lighting. c. Remove oxygen tubing from the room. d. Set firm behavioral limits.

ANS: C The first priority in caring for a mentally ill client is providing a safe environment. This would include removing any item that the client could use to harm himself or herself (or others). All the other interventions can be used in providing a therapeutic environment. However, they are not as imperative as the safety of the client and staff.

25. The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which action does the nurse perform first? a. Apply silver sulfadiazine (Silvadene) ointment. b. Cover the area with an elastic wrap. c. Place a synthetic dressing over the area. d. Remove loose nonviable tissue.

ANS: D All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process consists of removing exudates and necrotic tissue. This promotes wound healing.

27. The family of a client who has been burned asks when the client will no longer be at greater risk for infection. What is the nurse's best response? a. "As soon as the antibiotics have been finished." b. "As soon as albumin levels returns to normal." c. "When fluid remobilization has started." d. "When the burn wounds are closed."

ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open.

1. A client is in the emergency department with a burn calculated to be 35% TBSA. The nurse prepares the client for an IV insertion in which location? _________________

ANS: [subclavian vein] Clients with burns greater than 25% TBSA are at great risk for hypovolemic shock and need fluid resuscitation. The large volume of fluids this client needs will be delivered at a very rapid rate, so the IV needs to be a central venous catheter instead of a peripheral IV. All other sites are peripheral sites.

The nursing student is caring for the client with open wound burns. Which nursing interventions will the nursing student provide for this client? Select all that apply. A. Provides cushions and rugs for comfort B. Performs frequent handwashing C. Places plants in the client's room D. Performs gloved dressing changes E. Uses disposable dishes

B. Performs frequent handwashing D. Performs gloved dressing changes E. Uses disposable dishes Rationale Cushions and rugs are difficult to clean and may harbor organisms.

The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment? a. A patient with absent pedal pulses b. A patient with an open femur fracture c. A patient with a sucking chest wound d. A patient with bleeding of facial lacerations

C Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid intervention but do not have airway or breathing problems.

The nurse is providing care for a dying client. The nurse would place highest priority on treating which symptoms? (Select all that apply.) a. Anorexia b. Weight loss c. Pain d. Agitation e. Nausea f. Hair loss g. Dyspnea

C, D, E, G Only symptoms that cause distress for a dying client should be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the client's comfort. Even when symptoms, such as anorexia or weight loss, disturb the family, they should be treated only if the client is distressed by their presence. The nurse should provide education to the family and the client related to normal symptoms of dying.

Which strategies will the nurse include when teaching the college student about fire prevention in the dormitory room? A. Use space heaters to reduce electrical costs. B. Check water temperature before bathing. C. Do not smoke in bed. D. Wear sunscreen.

C. Do not smoke in bed. Rationale C. Smoking in bed increases the risk for fire because the person could fall asleep.

The client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A. Body temperature assessment B. Emotional support C. Fluid resuscitation D. Sterile dressing changes

C. Fluid resuscitation Rationale C. The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury.

In assessing the client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A. Acute Pain B. Potential for inadequate oxygenation C. Reduced self-image D. Potential for infection

C. Reduced self-image Rationale C. In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected.

Which clinical manifestation is indicative of wound healing for the client in the acute phase of burn injury? A. Pale, boggy, dry, or crusted granulation tissue B. Increasing wound drainage C. Scar tissue formation D. Sloughing of grafts

C. Scar tissue formation Rationale C. Indicators of wound healing include the presence of granulation, re-epithelization, and scar tissue formation.

The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury? A. Most of the wounded area is red. B. The client reports that the area hurts when touched. C. The area does not blanch when firm pressure is applied. D. Thrombosed blood vessels are visible beneath the skin surface.

D. Thrombosed blood vessels are visible beneath the skin surface. Rationale D. The presence of thrombosed blood vessels beneath the skin surface is a strong indication of a full-thickness injury. Partial-thickness injuries can directly damage more superficial blood vessels but do not cause thrombosis of deeper vessels. Reference: p. 515, Physiological Integrity

An older client was admitted to hospice owing to impending death in approximately 6 weeks. After 2 months, the family remains at the bedside but is becoming increasingly impatient and irritable. What is the best nursing intervention? a. Ask the family to leave and not return until they are calmer. b. Sit with the family and listen to their concerns and fears. c. Tell the family members not to worry, the client will die soon. d. Consult the chaplain to come and pray with the client's family.

b. Sit with the family and listen to their concerns and fears. Death cannot be accurately predicted. The nurse should sit with the family and listen to their concerns. The nurse should not provide false hope or reassurance. Family members should remain with the client as long as they would like. The chaplain should be consulted if the family requests.

The terminally ill client is prescribed morphine to help cope with increasing discomfort. A family member expresses concern that the client is on "too much morphine." What is the nurse's best response? a. "What has the physician told you about your family member's illness?" b. "Don't worry about that. We're following the physician's plan of care." c. "Tell me more about what you mean by too much morphine." d. "You should talk with your physician about this when he makes rounds."

c. "Tell me more about what you mean by too much morphine." Asking family members to explain what they mean by "too much morphine" serves to gain more information for the nurse. The other questions will not help the nurse obtain more information about the client's care or the family's concerns.

A dying client's family members are spending time with the client. What instruction is best to give to family members regarding noise in the client's room? a. "Remember that she cannot hear you." b. "Try to get her to talk or respond to you." c. "Avoid making any noise when you are with her." d. "Talk in your normal speaking voice."

d. "Talk in your normal speaking voice." The sense of hearing may remain intact, even when it appears that the client is totally unresponsive to any sort of stimuli. The family member should speak to the client as if she were fully aware

The health care provider suggests inpatient hospice for a client. The family members are concerned that their loved one will receive only custodial care. What is the nurse's best response? a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." b. "Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop." c. "A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given." d. "Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility."

a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity.

The nurse is caring for a client who is considering being admitted to hospice. What is the nurse's best response? a. "Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge." b. "Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms." c. "Hospice care will not help with your symptoms of depression. I will refer you to the facility's counseling services instead." d. "You seem to be experiencing some difficulty with this stage of the grieving process. Let's talk about your feelings."

b. "Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms." As both a philosophy and a system of care, hospice care uses an interdisciplinary approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client.

The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client's anxiety and restlessness. Which statement by the family member indicates understanding of the nurse's teaching? a. "Maybe we should just hire a round-the-clock sitter to stay with Grandmother." b. "I have some of her favorite hymns on a CD that I could bring for music therapy." c. "I don't think that she'll need pain medication along with her herbal treatments." d. "I will burn therapeutic incense in the room so we can stop the anxiety pills."

b. "I have some of her favorite hymns on a CD that I could bring for music therapy." Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a client's inner restlessness. Complementary therapies are used in conjunction with traditional therapy. The complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications. Hiring an around-the-clock sitter does not demonstrate that the client's family understands complementary therapies.

The family members of a client with a terminal illness tell a nurse that the client keeps asking if she is dying. What is the nurse's best response? a. "Whenever she asks about dying, change the subject." b. "Tell her the truth in as gentle a way as possible." c. "Tell her that she will get better eventually." d. "Ask her if she is afraid to die."

b. "Tell her the truth in as gentle a way as possible." Being honest and truthful at such a time is important. It helps the client develop trust in those caring for her. Changing the subject will frustrate the client and may make her distrustful. Providing false hope is not a realistic intervention. Asking a pointed question often will not elicit the information that you want from the client. It is better to ask open-ended questions.

The newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A. Painful red and white blisters B. Painless, brownish-yellow eschar C. Painful reddened blisters D. Painless black skin with eschar

A. Painful red and white blisters Rationale A. Painful red and white blisters accompany a deep partial-thickness burn.

When preparing to rewarm a patient with hypothermia, the nurse will plan to a. attach a cardiac monitor. b. insert a urinary catheter. c. assist with endotracheal intubation. d. have sympathomimetic drugs available.

A Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation.

A burned client newly arrived from an accident scene is prescribed 4 mg of morphine sulfate intravenously. What is the most important reason the nurse administers the analgesic to this client by the intravenous (IV) route? A. The drug will be effective more quickly than if given IM or subcutaneously. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client has delayed gastric emptying.

C. The danger of an overdose during fluid remobilization is reduced. Rationale Although providing some pain relief is a high priority and giving the drug by the IV route instead of the IM, subcutaneous, or oral routes does increase the rate of effect, the most important reason is to prevent an overdose from the accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed while the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area will be of greatest concern to the nurse? A. Bowel sounds are absent. B. The pulse oximetry level is 91%. C. The serum potassium level is 8.1 mEq/L. D. Urine output since admission is 370 mL.

C. The serum potassium level is 8.1 mEq/L. Rationale C. An elevated serum potassium level can cause cardiac arrest.

The nurse is evaluating the effectiveness of fluid resuscitation for the client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A. Blood urea nitrogen (BUN), 36 mg/dL B. Creatinine, 2.8 mg/dL C. Urine output, 40 mL/hr D. Urine specific gravity, 1.042

C. Urine output, 40 mL/hr Rationale C. Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL or 0.5 mL/kg/hr.

Which factors indicate that the client's burn wounds are becoming infected? Select all that apply. A. Dry, crusty granulation tissue B. Elevated blood pressure C. Hypoglycemia D. Swelling of the skin around the wound E. Tachycardia

A. Dry, crusty granulation tissue D. Swelling of the skin around the wound E. Tachycardia

The spouse of a dying client states that she is concerned that her husband is choking to death. What is the nurse's best response? a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your husband comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your husband on his side."

d. "I will have another nurse assist me to turn your husband on his side." The choking sound or "death rattle" is common in dying clients. The nurse should acknowledge the spouse's concerns and provide interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. Morphine will assist with comfort but will not decrease the choking sounds. Nasal tracheal suctioning is not appropriate in a dying client. The nurse should not minimize the spouse's concerns.

The client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A. Encouraging participation in wound care B. Encouraging visitors C. Reassuring the client that he or she will be fine D. Telling the client that these feelings are normal

A. Encouraging participation in wound care Rationale A. Encouraging participation in wound care will offer the client some sense of control.

A hospitalized American Indian client is approaching death. Family members who are standing vigil in the client's room begin to divide up his possessions among themselves as his symptoms progress. What is the nurse's most important intervention? a. Ask the family members to step outside the room so the client cannot hear them. b. Tell the family that they are being insensitive and their behavior is inappropriate. c. Recognize that this is a culturally appropriate activity and document it in the chart. d. Report these activities to the client's physician and the nursing supervisor.

c. Recognize that this is a culturally appropriate activity and document it in the chart. American Indians often disperse material possessions before or after death to friends and family members. Recognizing this culturally appropriate activity would not be consistent with removing the family, stopping the activity, or reporting the client's family's behaviors

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the hospital. Which of these patients will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a yellow tag d. A patient with a green tag

A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die.

The following actions are part of the routine emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Remove the patient's rings. b. Place ice packs on both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 100 mg PO.

A The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jewelry.

An 18-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate administration of a. tetanus-diphtheria toxoid (Td) only. b. tetanus immunoglobulin (TIG) only. c. TIG and tetanus-diphtheria toxoid (Td). d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 diazepam (Valium) tablets. Which action will the nurse plan to take first? a. Administer activated charcoal. b. Insert a large-bore orogastric tube. c. Prepare a 60-mL syringe with saline. d. Assist with intubation of the patient.

D In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

Which assessment will the nurse prioritize for the client in the acute phase of burn injury? A. Bowel sounds B. Muscle strength C. Signs of infection D. Urine output

C. Signs of infection Rationale C. The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery.

2. On admission to the emergency department, a client states that he feels like killing himself. When planning this client's care, it is most important for the nurse to coordinate with which member of the health care team? a. Case manager b. Forensic nurse examiner c. Physician d. Psychiatric crisis nurse

ANS: D The psychiatric crisis nurse interacts with clients and families in crisis. This health care team member can offer valuable expertise to the emergency health care team, which also includes the case manager and the physician.

A patient arrives in the emergency department after exposure to radioactive dust. Which action should the nurse take first? a. Place the patient in a shower. b. Obtain the patient's vital signs. c. Determine the type of radioactive agent. d. Obtain a baseline complete blood count.

A The initial action should be to protect staff members and decrease the patient's exposure to the radioactive agent by decontamination. The other actions can be done after the decontamination is completed.

When assessing a patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse notes multiple additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? a. "Is someone at home hurting you?" b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I have to report this abuse to the police."

A The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. The patient, not the nurse, is responsible for reporting the abuse. A social worker may be appropriate once further assessment is completed.

A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first action should be to: a. assess the patient's current vital signs. b. obtain a clean-catch urine for urinalysis. c. tell the patient that it may be several hours before being seen by the doctor. d. ask the health care provider to order an analgesic medication for the patient.

A The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with the data needed to determine this. The health care provider will not order a medication before assessing the patient.

The hospice nurse is caring for a dying client and her family members. What nursing interventions are appropriate to use? (Select all that apply.) a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. c. Assist family members by offering an explanation for their loss. d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the client's and the nurse's beliefs may not be congruent. f. Do not encourage hope for the terminally ill client.

A, B, D The nurse should teach family members about the physical signs of death, because family members often become upset when they see physiologic changes in their loved one. Palliative care includes management of symptoms so that the peaceful death of the client is facilitated. Reminiscence will help both the client and family members cope with the dying process. The nurse is not expected to explain why this is happening to the family's loved one. The nurse can encourage spirituality if the client is agreeable, regardless of whether her religion is the same.

The nurse is admitting a new client to the hospital and needs to determine the plan of care. What criterion is required for the client to make his own medical decisions? (Select all that apply.) a. Can communicate his treatment preferences b. Is able to read and write at an 8th grade level c. Is oriented enough to received information d. Can evaluate and deliberate information e. Has completed an advance directive

A, C, D To have decision-making ability, a person must be able to perform three tasks: receive information (but not necessarily oriented ×4); evaluate, deliberate, and mentally manipulate information; and communicate a treatment preference. The client does not have to read or write at a specific level. Education can be provided at the client's level, so that he can make the necessary decisions. The client does not need to complete an advance directive to make his own medical decisions. An advance directive will be necessary if he wants to designate someone to make medical decisions when he is unable to.

When teaching fire safety to parents at a school function, the school nurse offers advice about the placement of smoke and carbon monoxide detectors with which statement? A. "Every bedroom should have a separate smoke detector." B. "Every room in the house should have a smoke detector." C. "If you have a smoke detector, you don't need a carbon monoxide detector." D. "The kitchen and the bedrooms are the only rooms that need smoke detectors."

A. "Every bedroom should have a separate smoke detector." Rationale A. The number of detectors needed depends on the size of the home. Recommendations are that each bedroom should have a separate smoke detector, at least one detector should be placed in the hallway of each floor of the house, and at least one detector is needed for the kitchen, stairway, and home entrance.

The client who tripped while carrying an open kettle of hot water received scald burns to the entire chest, the entire anterior section of the right arm, the right half of the abdomen, and the anterior portion of the right leg from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines? A. 22% to 23% B. 30% to 31% C. 39% to 40% D. 48% to 49%

A. 22% to 23% Rationale: The anterior thorax, which includes the chest and abdomen, is 18% of the total body surface area. Therefore the entire chest and half of the abdomen would be 13.5%. The anterior right area adds another 4.5%, bringing the total to 18%. The anterior section of the right thigh adds another 4.5%, bringing the total body surface area involved in this injury to approximately 22% to 23%. Reference: p. 523, Physiological Integrity

The client with 45% burns has a hematocrit of 52% 10 hours after the burn injury and 6 hours after fluid resuscitation was started. What is the nurse's best action? A. Assess the client's blood pressure and urine output. B. Notify the physician or the Rapid Response Team. C. Document the report as the only action. D. Increase the IV infusion rate.

A. Assess the client's blood pressure and urine output. Rationale: The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to assess whether the fluid resuscitation at the current rate is adequate. The best ways to determine adequacy by noninvasive measures is by blood pressure measurement and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, it may need adjustment and the physician should be called.

What is the best method to prevent autocontamination for the client with burns? A. Change gloves when handling wounds on different areas of the body. B. Ensure that the client is in isolation therapy. C. Restrict visitors. D. Watch for early signs of infection.

A. Change gloves when handling wounds on different areas of the body. Rationale A. Gloves should be changed when wounds on different areas of the body are handled and between handling old and new dressings.

A client with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which physician request first? A. Give oxygen per non-rebreather mask at 100% FiO2. B. Infuse lactated Ringer's solution at 150 mL/hr. C. Give morphine sulfate 4 to 10 mg IV for pain control. D. Insert a 14 Fr retention catheter.

A. Give oxygen per non-rebreather mask at 100% FiO2. Rationale A. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level.

To position the client's burned upper extremities appropriately, how will the nurse position the client's elbow? A. In a neutral position B. In a position of comfort C. Slightly flexed D. Slightly hyperextended

A. In a neutral position Rationale A. The neutral position is the correct placement of the elbow to prevent contracture development.

The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A. Reduction of bacterial growth in the wound and prevention of systemic sepsis B. Prevention of cross-contamination from other clients in the unit C. Enhanced cell growth D. Reduced need for a skin graft

A. Reduction of bacterial growth in the wound and prevention of systemic sepsis Rationale A. Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds.

1. A client who weighs 90 kg and had a 50% burn injury at 10 AM arrives at the hospital at noon. Using the Parkland formula, calculate the rate that the nurse should use to deliver fluid when the IV is started at noon.

ANS: 1500 mL/hr The Parkland formula is 4 mL/kg/%total body surface area (TBSA) burn. This client needs 18,000 mL of fluid during the first 24 hours post burn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 post burn hours.

32. The nurse assesses a client in the burn unit after the client was repositioned by the nursing assistant. The nurse intervenes after finding the client repositioned in what manner? a. Supine with one pillow behind the head b. Semi-Fowler's position with arms elevated c. Wrists extended to 30 degrees in a splint d. A towel roll placed under the neck or shoulder

ANS: A Clients must be positioned to prevent contractures. The function that would be disrupted by a contracture to the posterior neck is flexion. The client should not be positioned with a pillow behind the head; this would increase flexion. The nurse must intervene and position the client so that neck flexion does not occur. The other options include proper positioning techniques that will help prevent contracture.

26. Which nursing intervention is likely to be most helpful in providing adequate nutrition while a client is recovering from a thermal burn injury? a. Allowing the client to eat whenever he or she wants b. Beginning parenteral nutrition high in calories c. Including 3000 kcal/day of calories with meals d. Providing a low-protein, high-fat diet

ANS: A Clients should request food whenever they think they can eat, not just according to the hospital's standard meal schedule. The nurse needs to work with a dietitian to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible; they may need as many as 5000 kcal/day. Specific caloric requirements can be determined by the dietitian. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications.

31. Which intervention by the nurse is most appropriate to reduce a client's pain after a burn injury? a. Administering morphine sulfate 4 mg intravenously b. Administering morphine sulfate 4 mg intramuscularly c. Applying ice to the burned area for 20 minutes d. Avoiding tactile stimulation near the burned area

ANS: A Drug therapy for pain management requires opioid and non-opioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. Tactile stimulation can be used for pain management. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area.

29. The nurse uses topical gentamicin sulfate (Garamycin) on a client's burn injury. Which laboratory value does the nurse monitor? a. Creatinine b. Red blood cells c. Sodium d. Magnesium level

ANS: A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium level.

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

ANS: A Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injury. Fluids can treat this problem. ECG and CBC will be taken to ascertain whether a cardiac or bleeding problem is causing these vital signs. However, these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery, but this is not an immediate nursing action.

18. Ten hours after a client with 50% burns is admitted, her blood glucose level is 152 mg/dL. What action by the nurse is most appropriate? a. Document the finding. b. Obtain a family history for diabetes. c. Repeat the glucose measurement. d. Stop IV fluids containing dextrose.

ANS: A Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma. A family history of diabetes could place her at higher risk for the disease, but this is not a priority at this time. The glucose level is not high enough to warrant retesting. The cause of her elevated blood glucose is not the IV fluid.

21. A client is brought to the emergency department by an emergency medical services (EMS) squad after being burned with unknown chemicals. The client's body is covered with a white, powdery substance, and the client cries out, "Get this stuff off me! It's burning me!" Which action by the nurse is most appropriate? a. Have the client take a shower, and bag all clothing. b. Brush the substance off the client and remove clothes. c. Call poison control to try to identify the chemical. d. Start an IV line and prepare to administer analgesics.

ANS: B A priority first action in burn care is to stop the burning process. Chemicals can continue to burn the client even after they have been removed, so removing them from the client is an important action. With unknown dry substances, adding water could potentiate their action, so the best action is to brush off as much of the chemical as possible from the client and clothing, then remove the clothing. Calling poison control would take too long if the chemical could be identified, and analgesics should be given after the burning process has been halted by removal of the offending substance.

The nurse is caring for the client with burns to the face. Which statement by the client requires further evaluation by the nurse? A. "I am getting used to looking at myself." B. "I don't know what I will do when people stare at me." C. "I know that I will never look the way I used to, even after the scars heal." D. "My spouse does not stare at the scars as much as in the beginning."

B. "I don't know what I will do when people stare at me." Rationale B. This statement indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques.

33. A client has severe burns around the right hip. Which position does the nurse instruct the nursing assistant to use to maintain maximum function of this joint? a. Hip maintained in 30-degree flexion b. Hip at zero flexion with leg flat c. Knee flexed at 30-degree angle d. Leg abducted with foam wedge

ANS: B Maximum function for ambulation occurs when the hip and the leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion.

23. A client has experienced an electrical injury of the lower extremities. Which priority assessment data should be obtained from this client? a. Range of motion in all extremities b. Heart rate, rhythm, and electrocardiogram (ECG) c. Respiratory rate and pulse oximetry d. Orientation to time, place, and person

ANS: B The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electrical 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 and rhythm, and ECG changes. Range-of-motion and neurologic assessments are important; however, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.

22. A client suffered a 45% total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds were absent in all four abdominal quadrants. Which is the nurse's best action? a. Administer a laxative. b. Document the finding. c. Prepare to insert a nasogastric (NG) tube. d. Reposition the client on the right side.

ANS: C Decreased or absent peristalsis is a frequent response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. The result is often a paralytic ileus. Clients who have burns greater than 25% TBSA or who are intubated generally need to have an NG tube inserted.

36. An older adult client with burns has a white blood cell count of 10,000/mm3. The client is afebrile with a heart rate of 110 beats/min, a respiratory rate of 20 breaths/min, and blood pressure of 112/68 mm Hg. The client's wound is pale, and edema is noted in the surrounding tissues. Which intervention by the nurse is most appropriate? a. Assess the client's skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.

ANS: C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. The other options would yield important data but do not take priority over determining whether the client has an infection.

17. A client is 24 hours post burn and has the following laboratory results. Which result does the nurse report to the health care provider immediately? a. Arterial pH, 7.32 b. Hematocrit, 52% c. Serum potassium,7.5 mEq/L d. Serum sodium, 131 mEq/L

ANS: C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

19. A client who was burned has crackles in both lung bases and a respiratory rate of 40 breaths/min and is coughing up blood-tinged sputum. Which action by the nurse takes priority? a. Administer digoxin. b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Digoxin may be given later to enhance cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid.

24. A client is receiving fluid resuscitation after a burn. Which finding indicates that fluid resuscitation is adequate for this client? a. Hematocrit = 60% b. Heart rate = 130 beats/min c. Increased peripheral edema d. Urine output = 50 mL/hr

ANS: D The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood pressure and heart rate, as well as laboratory values, to more normal levels.

28. A client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which action by the nurse is most appropriate? a. Continue to monitor the client. b. Increase the temperature in the room. c. Increase the rate of intravenous fluids. d. Prepare to do a workup for sepsis.

ANS: D These findings are associated with systemic Gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing the temperature in the room may make the client more comfortable, but the priority is finding out whether the client has sepsis and treating it before it becomes a shock situation. The rate of intravenous fluids may be increased to replace fluid losses associated with diarrhea, but this is not the priority action.

15. A client in the emergency department has died from a suspected homicide. What is the nurse's priority intervention? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.

ANS: D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of a. blood. b. vaccine. c. atropine. d. antibiotics.

B Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox.

When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first? a. Apical pulse b. Lung sounds c. Body temperature d. Level of consciousness

B The priority assessment data are how well the patient is oxygenating, so lung sounds should be assessed first. The other data also will be collected rapidly but are not as essential as the lung sounds.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A. "The last tetanus injection was less than 5 years ago." B. "Burn wound conditions promote the growth of Clostridium tetani." C. "The wood in the fire had many nails, which penetrated the skin." D. "The injection was prescribed to prevent infection from Pseudomonas."

B. "Burn wound conditions promote the growth of Clostridium tetani Rationale B. Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid, 0.5 mL given IM, enhances acquired immunity to C. tetani. This agent is routinely given when the client is admitted to the hospital.

The nurse on a burn unit has just received change-of-shift report about these clients. Which client will the nurse assess first? A. Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C. An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D. Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" Rationale B. Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The client with difficulty breathing needs immediate assessment and intervention.

The client is in the resuscitation phase of burn injury. Which route will the nurse use to administer pain medication to the client? A. Intramuscular B. Intravenous C. Sublingual D. Topical

B. Intravenous Rationale B. During the resuscitation postburn phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

The client with burns to the head, neck, and upper body from a house fire starts drooling uncontrollably about 8 hours after the injury. What is the nurse's best first action? A. Ensure that the client remains NPO. B. Notify the Rapid Response Team. C. Slow the IV infusion rate. D. Raise the head of the bed.

B. Notify the Rapid Response Team. Rationale The client is at high risk for an inhalation injury from the circumstances of the burn (enclosed space and burns to the the head, neck, and upper body). The drooling indicates oral and throat swelling. This client is in danger of losing a patent airway and needs emergency intubation now.

Several clients have been brought to the emergency department (ED) after an office building fire. Which client is at greatest risk for inhalation injury? A. Middle-aged adult who is frantically explaining to the nurse what happened B. Young adult who suffered burn injuries in a closed space C. Adult with burns to the extremities D. Older adult with thick, tan-colored sputum

B. Young adult who suffered burn injuries in a closed space Rationale B. The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke.

A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which action is best for the nurse to take initially? a. Have the family wait outside the patient room with a designated staff member to provide emotional support. b. Keep the family in the room and assign a member of the team to explain the care given and answer questions. c. Ask the family members about whether they would prefer to remain in the patient room or wait outside the room. d. Advise the family members that patients are comforted by having family members present during resuscitation efforts.

C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences.

A patient with hypotension and temperature elevation after doing yard work on a hot day is treated in the ED. After the nurse has completed discharge teaching, which statement by the patient indicates that the teaching has been effective? a. "I will take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I should have sports drinks when exercising outside in hot weather." d. "I will get into a cool environment if I notice that I am feeling confused."

C Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action.

The client who was the sole survivor in a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? A. "Do you want to pray about it?" B. "I know, and you will have to learn to adapt to a new body image." C. "Tell me more." D. "There must be a reason."

C. "Tell me more." Rationale C. This response encourages therapeutic grieving.

The nurse is caring for a burn client who is receiving topical gentamicin sulfate (Garamycin). What laboratory value will the nurse plan to monitor? A. Blood glucose B. C-reactive protein C. Serum and urine creatinine D. Platelet count

C. Serum and urine creatinine Rationale C. Topical gentamicin may have nephrotoxic effects, and the nurse should monitor serum and urine creatinine clearance before and during treatment.

A patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to take during the observation period? a. Listen to heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d. Check pupil reaction to light.

C Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse, but it is not as pertinent to the patient's admission diagnosis.

A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, the nurse should: a. assess the patient's vital signs. b. attach a cardiac electrocardiogram (ECG) monitor. c. obtain a Glasgow Coma Scale score. d. ask about chronic medical conditions.

C The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.

An unresponsive 78-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 106.2° F (41.2° C), blood pressure (BP) 86/52, and pulse 102. The nurse initially will plan to: a. administer an aspirin rectal suppository. b. start O2 at 6 L/min with a nasal cannula. c. apply wet sheets and a fan to the patient. d. infuse lactated Ringer's solution at 1000 mL/hr.

C The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.

These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed? a. A 72-year-old with palpitations and chest pain b. A 45-year-old complaining of 6/10 abdominal pain c. A 22-year-old with multiple fractures of the face and jaw d. A 30-year-old with a misaligned right leg with intact pulses

C, A, B, D The highest priority is to assess the 22-year-old patient for airway obstruction, which is the most life-threatening injury. The 72-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 45-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 30-year-old appears to have a possible fracture of the right leg and should be seen soon, but this patient has the least life-threatening injury.

The nurse is caring for the client with burns. Which question will the nurse ask the client and family to assess their coping strategies? A. "Do you support each other?" B. "How do you plan to manage this situation?" C. "How have you handled similar situations before?" D. "Would you like to see a counselor?"

C. "How have you handled similar situations before?" Rationale C. This question assesses whether the client's and the family's coping strategies may be effective.

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F, which assessment indicates that the nurse should discontinue the rewarming? a. The patient stops shivering. b. The BP decreases to 85/40 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).

D A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient.

During the primary survey of a patient with multiple traumatic injuries, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen. Which of these actions will the nurse take next? a. Assess further for a cause of the decreased circulation. b. Send blood to the lab for a complete blood count (CBC). c. Finish the airway, breathing, circulation, disability survey. d. Initiate isotonic fluid infusion through two large-bore IV lines.

D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

The burn client asks the nurse not to remove the loosened bits of skin and tissue during the dressing change, saying "The more skin you take off, the longer it will take me to heal." What is the nurse's best response? A. "Do you want some pain medication before I begin?" B. "The only things I am removing are blocks of bacteria growth, not skin." C. "Don't worry, I have worked the burn unit for years and know what I am doing." D. "This tissue is no longer living and as long as it is present, real healing cannot start."

D. "This tissue is no longer living and as long as it is present, real healing cannot start." Rationale D. Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful. Reference: p. 532, Psychosocial Integrity

When delegating care for clients on the burn unit, which client will the charge nurse assign to an RN who has floated to the burn unit from the pediatric unit? A. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B. Recently admitted client with a high-voltage electrical burn C. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D. Client receiving IV lactated Ringer's solution at 100 mL/hr

D. Client receiving IV lactated Ringer's solution at 100 mL/hr Rationale D. An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath.

The client is in the acute phase of burn injury. In which situation will the nurse decide to coordinate with the dietitian? A. Discouraging having food brought in from the client's favorite restaurant B. Providing more palatable choices for the client C. Helping the client lose weight D. Planning additions to the standard nutritional pattern

D. Planning additions to the standard nutritional pattern Rationale D. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What will the nurse do first? A. Administer a diuretic. B. Provide a fluid bolus. C. Recalculate fluid replacement based on time of hospital arrival. D. Titrate fluid replacement.

D. Titrate fluid replacement. Rationale D. The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids).

5. The nurse is working with a paramedic who just finished assisting at the scene of a school shooting where several students were killed. Which statement by the nurse is most therapeutic? a. "Would you like to talk about what happened?" b. "Surely the department will give you the day off tomorrow." c. "At least the gunman was taken into custody." d. "Let's just sit here for a while quietly."

ANS: A Allowing staff members to ventilate their feelings about the incident can facilitate recovery and effective coping afterward. The other choices do not facilitate open communication because the nurse is not providing the opportunity for the paramedic to talk.

14. The emergency department nurse manager is explaining concepts of emergency and disaster preparedness to a group of students. Which statement by the nurse manager is most accurate? a. "An internal disaster is something that occurs inside the health care facility." b. "An external disaster occurs when someone not employed here disrupts our operations." c. "A multi-casualty event involves disasters at several different locations." d. "The Joint Commission requires that we participate in a disaster drill once a year."

ANS: A An internal disaster is something that occurs within the health care facility, such as a fire. External disasters, such as a tornado or a hurricane, occur outside the health care facility. A multi-casualty event can be managed with hospital resources. The Joint Commission requires hospitals to participate in two disaster drills a year.

10. A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority? a. Apply oxygen and continuous pulse oximetry. b. Allow the client to suck on small quantities of ice chips. c. Request an antitussive medication from the physician. d. Have the respiratory therapist provide humidified room air.

ANS: A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

22. A hospital has "stood down" from a mass casualty disaster. The staff have rested and eaten. Which action by the nursing supervisor takes priority? a. Restocking the emergency department (ED) b. Making rounds on each unit to check staffing c. Determining which staff can go home d. Planning a critical incident stress debriefing

ANS: A Inventorying and stocking the ED are high-priority actions because the usual flow of emergency clients may not be lessened in the wake of a disaster. Supplies may be low or exhausted, and it would be vital to resupply the area. Rounding on inpatient units, determining the staff who can be relieved, and planning a debriefing are certainly important items, but they do not take priority over getting the ED ready for more clients.

23. A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention by the nurse is most beneficial? a. Offer the family choices as appropriate and possible. b. Call the hospital chaplain to stay with the family. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

ANS: A Offering choices when appropriate and when possible gives some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may appreciate privacy, but this is not as helpful as allowing choices when the family is able to make them.

19. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The Health Department d. A Disaster Medical Assistance Team

ANS: A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The Health Department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

8. An accident has occurred near the hospital, and a victim is brought to the emergency department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60 mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of breath and diaphoresis. Which color tag does the nurse use when triaging this client? a. Red b. Yellow c. Green d. Black

ANS: A The client in the emergent triage category has a condition that may post an immediate threat to life or limb and is given the highest priority. Clients who should be treated emergently receive a red tag. Yellow tags signify major but stable injuries that can wait 30 minutes to 2 hours for definitive care. Green tags designate "walking wounded" who can wait longer than 2 hours to receive care. Black tags are used to designate those who are dead or who are expected to die.

16. A nursing administrator is evaluating the hospital's response to a recent internal disaster. The administrator assesses that goals for disaster planning have been met when which outcome is assessed? a. The hospital was able to maintain client, staff, and visitor safety during the disaster. b. Supplies were readily available and were transported rapidly where needed. c. The hospital incident command officer successfully utilized ancillary areas for client care. d. All employees followed the chain of command and established policies and procedures.

ANS: A The most important outcome of any internal disaster is maintenance of safety for the hospital's clients, staff, and visitors. Other outcomes listed would be part of a successful disaster response, but are all too narrow to meet this objective.

6. The nurse has provided instruction on the facial pressure garment to a client with facial burns. Which statement indicates that the client understands these instructions? a. "My scars should be less severe with the use of this mask." b. "The mask will help protect my skin from sun damage." c. "This treatment will help prevent infection." d. "Using the mask will keep scars from being permanent."

ANS: A The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive, newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not alter the risk for infection.

11. The nurse is teaching nursing students about personal emergency preparedness. Which statement by a student indicates that further teaching is indicated? a. "I will get a prescription for antibiotics just in case I have to work in an area that has been infected with anthrax." b. "I should keep an extra uniform in my locker in case I get stuck at work." c. "I may be torn between caring for my young daughter and caring for victims at work." d. "I should make plans for my family to evacuate our house in case of tornado or earthquake."

ANS: A The student would have no reason to obtain a prescription for anthrax unless he or she demonstrates clinical evidence of anthrax infection or has been exposed to a substance that tests positive for anthrax. Statements about planning to keep an extra uniform at work, recognizing the moral dilemmas he or she might encounter when working in a disaster situation, and understanding personal preparation for disasters all indicate that the student comprehends information about disaster planning and emergency preparedness.

20. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. What statement by the nursing supervisor best addresses these concerns? a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states." b. "The government has a program for quick licensure activation wherever you are deployed." c. "During a time of crisis, licensure issues would not be the government's priority concern." d. "If you are deployed, you will be issued a temporary license in the state in which you are working."

ANS: A When deployed, DMAT health care providers are acting as agents of the government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

16. A new nurse is orienting to the emergency department (ED). Which statement made by the nurse would indicate the need for further education by the preceptor? a. "The emergency medicine physician coordinates care with all levels of the emergency health care team." b. "Emergency departments have specialized teams that deal with high-risk populations of patients." c. "Many older adults seek emergency services when they are ill because they do not want to bother their primary health care provider." d. "Emergency departments are responsible for public health surveillance and emergency disaster preparedness."

ANS: A The emergency nurse is one member of the large interdisciplinary team that provides care for clients in the ED. A collaborative team approach to emergency care is considered a standard of practice. In this setting, the nurse coordinates care with all levels of health care team providers, from prehospital emergency medical services (EMS) personnel to physicians, hospital technicians, and professional and ancillary staff.

4. A hospital is receiving large numbers of casualties from a disaster. Which clients does the supervisor identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Client who had open reduction and internal fixation of a femur fracture 3 days ago b. Client who had a colostomy 4 days ago and whose daughter is a registered nurse c. Client admitted last night with community-acquired pneumonia d. Infant admitted 2 days ago for fever of unknown origin e. Client in the medical decision unit for evaluation of chest pain

ANS: A, B The client with the femur fracture could be transferred to a rehabilitation facility and the RN could provide care and teaching to her father. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. Also, the infant has not been in the hospital long enough for cultures to return for a definitive diagnosis. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain.

6. A wing of a hospital is on fire. Which actions by the nurse promote safe evacuation of clients? (Select all that apply.) a. Direct ambulatory clients on where to go to be safe. b. Use ambulatory clients to help push clients in wheelchairs. c. Use oxygen tanks for all clients who are on oxygen. d. Manually ventilate clients who are on ventilators. e. Move bedridden clients in their beds if possible.

ANS: A, B, D, E Ambulatory clients can evacuate themselves with direction or could be used to help push wheelchair-bound clients. Clients on ventilators need to be removed from the ventilator and "bagged" until evacuated, then they can be put back on the ventilator if one is available. Bedridden clients should be moved in their beds or on stretchers, or carried if needed. Any client who can breathe without oxygen should have it removed for the evacuation because oxygen is an accelerant.

2. The nurse is discharging an older adult client home from the emergency department (ED) after an acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select all that apply.) a. Reconcile the client's prescription and over-the-counter medications b. Screen the client for functional and cognitive abilities, as well as risk for falls c. Consult physical therapy to organize for home health services d. Arrange for the client's car keys to be taken to prevent an accident e. Review discharge instructions with the client and a family member

ANS: A, B, E Before discharge, the nurse should ensure that the client's prescription and over-the-counter medications are evaluated to determine whether the drug regimen should be continued. Discharge education should be provided to the client and a significant other or family member. To prevent future ED visits, screen older adults per agency policy for functional assessment, cognitive assessment, and risk for falls. Case management should be consulted to organize home health services. The nurse should emphasize safety when driving but cannot organize to take the client's keys away.

1. The emergency department (ED) nurse is preparing to transfer a client to the critical care unit. What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Allergies b. Vital signs c. Immunizations d. Marital status e. Isolation precautions

ANS: A, B, E Hand-off communication should be comprehensive so that the nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, transmission-based precautions needed, interventions provided, and response to those interventions.

2. The triage nurse is assessing a client who has been brought to the emergency department (ED) by emergency medical services (EMS) following a mass casualty incident. Which assessment questions are used to determine the appropriate triage category for the client? (Select all that apply.) a. "Can you wiggle your toes?" b. "Are you having any difficulty breathing?" c. "Are you allergic to any medications?" d. "Does your family know that you are here?" e. "Can you tell me what day it is?" f. "Do you have any abdominal or back pain?"

ANS: A, B, E, F The triage nurse should assess for possible spinal cord injury, shortness of breath, abdominal or back pain, and disorientation when the client is brought to the ED. Determining allergies, although important, does not assist in categorizing clients, nor does inquiring about the client's family.

5. The nurse working with survivors of a disaster wants to assess them for post-traumatic stress disorder. For which clients does the nurse perform further assessment before administering the Impact of Event Scale-Revised? (Select all that apply.) a. Older adult survivor with minor injuries b. Woman who lost both her children c. Middle-aged victim with multiple medical problems d. Young adult who had serious orthopedic injuries e. Older adolescent who had a traumatic brain injury

ANS: A, E The Impact of Event Scale-Revised tool should not be used with people who have short-term memory loss, so the nurse should assess the older adult survivor and the client with the brain injury for this problem before administering the tool. The other clients do not have medical issues that would preclude use of this tool.

3. A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most appropriate? a. Document findings on the client's chart and inform the physician. b. Perform additional assessments for post-traumatic stress disorder. c. Educate the client on nonpharmaceutical methods to promote sleep. d. Plan to initiate a referral to a psychologist experienced in survivor issues.

ANS: B An individual may experience physical symptoms as a normal response to profound grief or loss, particularly after a traumatic incident. Manifestations such as insomnia, being startled easily, having flashbacks, or feelings of numbness may indicate post-traumatic stress disorder, and the nurse should first assess for this problem. The nurse should document assessment findings, but only after performing a more thorough assessment. A referral may be necessary, but the nurse does not have enough information yet to initiate it. If assessment reveals that methods to assist with sleep would be helpful, the nurse could provide that education.

2. When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? a. Avoid sharing equipment such as blood pressure cuffs between clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Use proper and consistent handwashing by all members of the staff.

ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client's body can prevent autocontamination.

21. A community disaster has occurred and the hospital's emergency department (ED) has efficiently triaged, treated, and transferred most clients to appropriate units. The hospital incident command officer wants to "stand down" from the emergency plan. Which question by the nursing supervisor is most beneficial at this time? a. "Are you sure no more victims are coming into the ED?" b. "Do all other areas of the hospital have the supplies and personnel they need now?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Are all other incident command officers and house supervisors in agreement with you?"

ANS: B Before "standing down," the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more "walking wounded" victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although agreement among incident officers is important, it is not the priority concern before standing down.

4. 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 an escape route everyone knows about. b. Keep a smoke detector in each bedroom. c. Use space heaters instead of gas heaters. d. Use carbon monoxide detectors in the garage.

ANS: B Everyone should use smoke detectors and carbon monoxide detectors in their home environment (just not in a garage). Recommendations are that each bedroom should have a separate smoke detector. Smoke detectors should also be placed in the hallway of each story, in the kitchen, in each stairwell, and by each entrance. Space heaters can be a cause of fire if clothing, bedding, and other flammable objects are nearby. An escape route is very important, but successfully escaping also depends on early recognition of a fire, which is assisted by smoke detectors.

16. A client who is receiving fluid resuscitation per the Parkland formula after a serious burn continues to have urine output ranging from 0.2 to 0.25 mL/kg/hour. After the health care provider checks the client, which order does the nurse question? a. Increase IV fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes stat.

ANS: B Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this client's inadequate urine output, fluids need to be increased. The other orders are appropriate.

12. A client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How does the nurse categorize this injury? a. Full thickness b. Partial thickness superficial c. Partial thickness deep d. Superficial

ANS: B The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters; and pain. Blisters are not seen with full-thickness and superficial burns and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns appear red to white.

17. A nursing administrator is reviewing a hospital's disaster planning. The administrator evaluates the plan that addresses which component as being the best? a. Internal disasters such as fires or power outages b. All possible catastrophes in the community c. The Joint Commission's assessment of possible disasters d. Responses to all types of weather-related emergencies

ANS: B When The Joint Commission-accredited health care facilities are planning disaster preparedness programs, they need to take an "all-hazards approach" (versus planning by strict guidelines) and to plan for all credible threats to the community that could result in a disaster. This means planning for all events that could conceivably happen in that geographic area, including possible weather events. Planning only for internal disasters is too limited and does not account for weather- or terrorist-related threats. The Joint Commission does not assess what disasters are possible in the areas that accredited hospitals serve.

17. An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first? a. Place the client on a non-rebreather mask. b. Begin bag-valve-mask ventilation. c. Initiate cardiopulmonary resuscitation. d. Prepare for chest tube insertion.

ANS: B Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax.

13. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

4. The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client's plan of care? a. Administer a sedative medication. b. Ask a family member to stay with the client. c. Use restraints to prevent the client from falling. d. Place the client in a wheelchair at the nurses' station.

ANS: B Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls.

5. An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Triage the client to determine the urgency of care. b. Clearly communicate client data to the unit nurse. c. Evaluate the need for ongoing medical treatment. d. Perform a thorough assessment of the client.

ANS: B The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client's ED experience.

1. A large number of victims arrive at the emergency department after a bus is hit by a train. Which interventions are performed immediately for red-tagged victims? (Select all that apply.) a. Splinting a closed tibial fracture b. Intubating a cyanotic client in respiratory distress c. Initiating IV fluids for a client with a blood pressure of 96/60 mm Hg and a pulse of 144 beats/min d. Attaching an external pacemaker for a client with a heart rate of 44 beats/min e. Performing postmortem care for a client who has just died f. Removing glass that is embedded in a client's arm

ANS: B, C, D Priority interventions are those that must be performed to save the client's life, including intubation, IV fluid replacement for shock, and pacemaker placement. Splinting a fracture and removing glass from a client's arm can wait until after life-threatening injuries are cared for. Postmortem care would wait until after all clients have been cared for.

3. The nurse is teaching burn prevention to a community group. Which information shared by a member of the group causes the nurse the greatest concern? a. "I get my chimneys swept every other year." b. "My hot water heater is set at about 120 degrees." c. "Sometimes I wake up at night and smoke." d. "I use a space heater when it gets below zero."

ANS: C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding. But the most immediate concern is the person's smoking upon waking up at night.

18. A nursing instructor is debriefing students who participated in a community-wide disaster drill. Several students are upset with the black-tagged triage category. Which statement by the nursing instructor is best? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

ANS: C In a disaster, military style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not "sacrificed." Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

7. Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance? a. Allowing family members to change the dressings b. Discussing future surgical reconstruction c. Performing morning care independently d. Wearing the pressure dressings as ordered

ANS: C Indicators that the client with a burn injury has a positive perception of his appearance include his or her willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

14. A client who is burned is drooling and is having difficulty swallowing. Which action does the nurse take first? a. Assess level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and mainstem bronchi. d. Measure abdominal girth and auscultate bowel sounds.

ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. Absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important, in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

5. A client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide? a. "With reconstructive surgery, you can look the same." b. "We can remove the scars with the use of a pressure dressing." c. "You will not look exactly the same but cosmetic surgery will help." d. "You shouldn't start worrying about your appearance right now."

ANS: C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring. They cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

25. A client has been treated in the emergency department after a tornado and is awaiting discharge instructions. This client is close to losing control, although other family members are attempting to calm him down. Which response by the nurse is most helpful? a. Call security and have them standing by in case they are needed. b. Instruct the person to leave the area until he can calm down. c. Offer the client the choice of waiting in the treatment room or the waiting room. d. Ask the family to help move the client out of the treatment area.

ANS: C Offering people choices often is a good way to get them to focus on something other than their distress. Calling security and telling the person to leave might escalate the situation, although if all other methods fail, the safety of staff, clients, and other visitors takes priority. Asking the family to help move the client puts him in a difficult position and may end up causing them injury.

11. A client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding is present, and the client describes just a "small amount of pain." How does the nurse categorize this injury? a. Partial thickness deep b. Partial thickness superficial c. Full thickness d. Superficial

ANS: C The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness burns are deep red to white and painful, and superficial burns are pink to red and are also painful.

6. A young man comes into the foyer of the hospital and says that he has a container of anthrax, which he opens and pours on the floor. Which is the priority action for the nurse who first comes upon the scene? a. Don a protective gown, mask, and goggles. b. Escort the man to the decontamination room. c. Begin to evacuate the immediate area. d. Notify the local health department of a biohazard situation.

ANS: C The highest priority is to remove people from immediate danger, so the nurse should evacuate the immediate area and prevent injury to those near the spill. Donning personal protective equipment would probably take the nurse away from the scene to obtain the equipment and would not help protect those in immediate danger. The man may need to be escorted to a decontamination area after people are removed from the scene. Reporting the incident to the health department should be done after the scene is secured and could be delegated to someone else.

9. A nurse is working at the scene of a catastrophic natural event. Which person does the nurse attend to first? a. Distraught mother looking for her children b. Person walking about with a bleeding head wound c. Supine person with pale, cool, clammy skin d. Child with a deformed lower leg crying in pain

ANS: C The person with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

24. An emergency department (ED) supervisor has noted an increase in sick calls and bickering among the ED staff after a week with multiple trauma incidents. What action by the supervisor is most helpful? a. Organize a pizza party for each shift. b. Remind staff of facility sick-leave policy. c. Arrange critical incident stress debriefing. d. Talk individually with staff members.

ANS: C The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. The other interventions may be helpful as well but are not as important as a debriefing.

11. A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face, as well as an open right femur fracture that is bleeding profusely. What will the nurse do first? a. Splint the right lower extremity. b. Apply direct pressure to the leg. c. Assess for a patent airway. d. Start two large-bore IVs.

ANS: C The highest-priority intervention in the primary survey is to establish a patent airway. Without an adequate airway to supply oxygen to the cells, a cerebral injury could progress to anoxic brain death. After an airway is established, resuscitation may continue to B for breathing and C for circulation assessment.

1. The nurse has been assigned the role of triage nurse after a weather-related disaster. What is the priority action of the nurse? a. Call in additional staff to assist with care of the victims. b. Splint fractures and clean and dress lacerations. c. Perform a rapid assessment of clients to determine priority of care. d. Provide psychological support to staff and family members.

ANS: C The triage nurse classifies victims of the explosion into priority of care based on illness or injury severity. Calling in additional staff more likely would be done by the hospital incident commander or designee. Physical care is provided to victims after triage occurs. Psychological support should be an ongoing part of the disaster plan but is not included in triage responsibilities; this ensures that the greatest good is provided to the greatest number of people.

13. The nurse is caring for a client whose wife just died in an accident. The client says to the nurse, "I can't believe that my wife is gone and I am left to raise my children all by myself." Which response by the nurse is most appropriate? a. "Please accept my sympathy for your loss." b. "I can call the hospital chaplain if you wish." c. "You sound anxious about being a single parent." d. "At least your children still have you in their lives."

ANS: C Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client's distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client's feelings and situation.

13. A client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse's best response? a. "Tagamet will stimulate intestinal movement so you can eat more." b. "Tagamet can help prevent hypovolemic shock, which can be fatal." c. "This will help prevent stomach ulcers, which are common after burns." d. "This drug will help prevent kidney damage caused by dehydration."

ANS: C Ulcerative gastrointestinal disease (Curling's ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage.

8. A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent? a. Chest pain and diaphoresis b. Decreased breath sounds due to chest trauma c. Left arm fracture with palpable radial pulses d. Sore throat and a temperature of 104° F

ANS: C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent.

14. The nurse is triaging clients in the emergency department. Which client should be considered urgent? a. 20-year-old female with a chest stab wound and tachycardia b. 45 year-old homeless man with a skin rash and sore throat c. 75-year-old female with a cough and of temperature of 102° F d. 50-year-old male with new-onset confusion and slurred speech

ANS: C A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

1. While assessing a client in the emergency department, the nurse identifies that the client has been raped. Which health care team member should the nurse collaborate with when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

ANS: C All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

20. The nurse is caring for a homeless client and consults the emergency department (ED) case manager. What can the ED case manager do for this client? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

ANS: C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

19. The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage? a. Treat clients on a first-come, first-serve basis. b. Identify and treat clients with low acuity first. c. Prioritize clients based on illness severity. d. Determine health needs from a complete assessment.

ANS: C ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the "head of the line."

2. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at the nurse when dinner is served late. What is the nurse's best response? a. "Do you need something for pain right now?" b. "Please stop yelling. I brought dinner as soon as I could." c. "I suggest that you get control of yourself." d. "You seem upset. I have time to talk if you like."

ANS: D Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client's options. Simply telling the client to gain control does nothing to promote therapeutic communication.

4. An industrial accident has occurred near the hospital, and many victims are brought to the emergency department (ED) for treatment of their injuries. The nurse triages the victim with which injury with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

ANS: D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the "walking wounded" and classified as nonurgent.

15. On assessment, the nurse notes that a 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. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowler's position. d. Gather appropriate equipment and prepare for intubation.

ANS: D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation.

1. The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN? a. Administer the prescribed tetanus toxoid vaccine. b. Assess wounds for signs of infection. c. Have the client cough and breathe deeply. d. Wash hands on entering the client's room.

ANS: D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.

7. Which is the priority action for the emergency department charge nurse in the event of a mass casualty situation? a. Directing medical-surgical and case management nurses to assist emergency department (ED) staff with critically injured victims b. Calling additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in c. Informing the incident commander at the mass casualty scene about how many victims may be handled by the ED d. Directing medical-surgical and critical care nurses to assist with clients who are already in the ED while the ED staff prepares to receive the mass casualty victims

ANS: D The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive the mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.

10. The hospital is overwhelmed when caring for victims after an earthquake that occurred 48 hours ago. Which responsibility of the nursing supervisor is most important at this time? a. Assuming leadership for implementation of the hospital emergency plan b. Releasing updates of client conditions to the media c. Converting the physical therapy clinic into a treatment area for the injured d. Arranging relief and coordinating breaks so nursing staff can rest and eat

ANS: D The nursing supervisor should ensure that the staff is not becoming dangerously overtired by working long shifts without food or rest. Overall leadership for implementing the emergency plan and re-designating areas for client care would fall under the job of hospital incident commander. The community relations/public information officer would work with the media.

6. The nurse manager is assessing current demographics of the facility's emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat? a. Older adults b. Immunocompromised people c. Pediatric clients d. Underinsured people

ANS: D The ED serves as an important safety net for clients who are ill or injured but lack access to basic health care. Especially vulnerable populations include the underinsured and the uninsured, who may have nowhere else to go for health care.

1. The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.) a. A 50-year-old with chest trauma and difficulty breathing b. A mother frantically looking for her 6-year-old son c. An 8-year-old with a broken leg in his father's arms d. A 60-year-old with facial lacerations and confusion e. A pulseless male with a penetrating head wound

ANS: a, d, b, c, e Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client with chest trauma and difficulty breathing is the priority because no clients have an airway problem, and this is the only client with a breathing problem. The client with confusion should be seen next. Confusion can be caused by lack of oxygen to the brain due to a circulation problem. The pulseless client with a penetrating head wound is seen last because there are multiple clients to be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can wait. The mother looking for her son should be seen third. Finding the child is urgent to identify potential injuries.

2. In what sequence would a client move through the process of admission to disposition in emergency care? (Place in order of priority.) a. Client is transported to the medical-surgical floor. b. Emergency department (ED) nurse gives a report on the client. c. Paramedics arrive and start IV access. d. Nurse and other health care provider(s) perform assessment. e. Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring. f. Laboratory technician obtains blood specimens.

ANS: e, c, d, f, b, a When clients are in an emergency situation, EMTs arrive on the scene first. EMTs apply oxygen and obtain vital signs to determine a baseline for further care. EMTs can provide basic life support measures and can assess ABCs. Second on the scene are paramedics. Starting IV access and performing advanced life support is within the paramedic's scope of practice. The client is then transported to an ED, where nurses and other health care providers perform an initial assessment. Laboratory technicians are notified and appropriate blood specimens are obtained for diagnostic testing. When the client is stable, the ED nurse gives report to the medical-surgical unit nurse, and the client is finally transferred to an inpatient room.

The wife is concerned because her terminally ill husband does not want to eat. What is the nurse's best response? a. "Let him know that food is available if he wants it, but do not insist that he eat." b. "A feeding tube can be placed in the nose to provide important nutrients." c. "Force him to eat even if he does not feel hungry, or he will die sooner." d. "He is getting all the nutrients he needs through his intravenous catheter."

a. "Let him know that food is available if he wants it, but do not insist that he eat." When family members understand that the client is not suffering from hunger and is not "starving to death," they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family.

A terminally ill client has just died in a hospital setting with family members at the bedside. The health care provider is also present. What should be the nurse's priority intervention as postmortem care begins? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask the family members if they would like to spend time alone with the client. c. Ensure that a death certificate has been completed by the physician. d. Request family members to prepare the client's body for the funeral home.

b. Ask the family members if they would like to spend time alone with the client. Before moving the client's body to the funeral home, the nurse should ask family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a death certificate has been completed before the client is moved to the mortuary, the nurse first should ask family members if they would like to be alone with the client. The client's family should not be expected to prepare the body for the funeral home.

A client who is near death appears to be having difficulty breathing. What is the nurse's highest-priority intervention? a. Teach the family how to perform nasotracheal suctioning. b. Request that the physician order morphine sulfate. c. Document the finding in the client's chart. d. Call a respiratory therapist to intubate the client.

b. Request that the physician order morphine sulfate. Morphine sulfate is the standard treatment for dyspnea near death; it relieves the psychological and physiologic distress that accompanies breathlessness. Suctioning or intubation may cause the client discomfort. Documentation is important, but it is not the priority intervention because it does nothing to relieve the client's distress

The nurse is assessing the dying client. Which manifestations of a dying client should the nurse assess to determine whether the client is near death? a. Level of consciousness b. Respiratory rate c. Bowel sounds d. Pain level on a 0 to 10 scale

b. Respiratory rate All of these assessments should be performed during the dying process. As the peripheral circulation decreases, the client's level of consciousness and bowel sounds decrease. The client is unable to provide a numeric number on a pain scale. The nurse should continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near.

The client's family members are concerned that the client should have a urinary catheter placed because of her decreasing urinary output. What is the hospice nurse's best response? a. "A Foley catheter is inserted only if she is taking medications that affect output." b. "I will insert a Foley catheter if her urinary output drops below 500 mL/day." c. "A Foley catheter will be inserted if her bladder becomes distended." d. "I will insert a Foley catheter if she becomes incontinent of urine."

c. "A Foley catheter will be inserted if her bladder becomes distended." Insertion of an indwelling catheter is acceptable if the client is unable to void, has a distended bladder, and would be more comfortable not moving. The other statements are not appropriate uses for an indwelling catheter in a hospice setting.

The nurse is discussing advance directives with a client. Which statement by the client indicates good understanding of the purpose of an advance directive? a. "An advance directive will keep my children from selling my home when I'm old." b. "An advance directive will be completed as soon as I'm incapacitated and can't think for myself." c. "An advance directive will specify what I want done when I can no longer make decisions about health care." d. "An advance directive will allow me to keep my money out of the reach of my family."

c. "An advance directive will specify what I want done when I can no longer make decisions about health care." An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client's residence in his or her own home.

An experienced hospice nurse is training a new nurse in the practices of palliative care. What statement by the new nurse indicates understanding about drug therapy for end-of-life care? a. "I can administer as much pain medication as I want because the client is dying." b. "The administration of these medications will hasten the client's death." c. "I can administer medication per the protocol to relieve the client's symptoms." d. "The purpose of palliative sedation is to relieve family members' distress."

c. "I can administer medication per the protocol to relieve the client's symptoms." Palliative care nurses follow protocols when administering medications. These protocols are standing prescriptions from the provider that identify the appropriate medication, dose, and situation for administration. The nurse cannot administer more than is prescribed. The medications are given to promote comfort and if administered per protocol will not hasten death.

An intensive care nurse is discussing withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. What is the nurse's best response? a. "I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia." b. "You will need to talk to the provider because I am not legally allowed to participate in the withdrawal of life support." c. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death." d. "There is no need to worry. Most religious organizations support the client's decision to stop medical treatment."

c. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death." The nurse should validate the family's concerns and provide accurate information about the discontinuation of therapy. The other statements address specific issues related to the withdrawal of care but do not provide appropriate information about its purpose. If the client's family asks for specific information about euthanasia, legal, or religious issues, the nurse should provide unbiased information about these topics.

The nurse is providing care for a hospice client who is in the last stages of the dying process. The client develops a pressure ulcer on her sacrum, and family members tell the nurse that they would like a specialist consulted to treat the ulcer. When the nurse discusses this with the client, the client states that the ulcer does not bother her, that it is not causing her pain, and that she'd rather not have additional caregivers at this time. What should the hospice nurse do next? a. Tell the family the wound care specialist will be consulted and treatment will begin. b. Ask the social worker and the chaplain to talk with family members about the dying process. c. Explain the client's desires to the family, emphasizing that the client will be made as comfortable as possible. d. Ask the agency mental health nurse to speak with the client about refusing treatment.

c. Explain the client's desires to the family, emphasizing that the client will be made as comfortable as possible. When palliative care is provided to the dying client, symptoms will be actively treated only if they are causing the client distress. In this case, the client has stated that the pressure ulcer is not causing her distress, and she does not want further intervention.

The client tells the nurse that even though it has been 4 months since her sister's death, she frequently finds herself crying uncontrollably. The client is afraid that she is "losing her mind." What is the nurse's best response? a. "Most people move on within a few months. You should see a grief counselor." b. "Whenever you start to cry, distract yourself from thoughts of your sister." c. "You should try not to cry. I'm sure your sister is in a better place now." d. "Your feelings are completely normal and may continue for a long time."

d. "Your feelings are completely normal and may continue for a long time." Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the client's response.

The nurse is caring for a dying client who becomes very agitated. What is the nurse's best response? a. Use music therapy to promote relaxation. b. Increase the dose of intravenous opioids. c. Provide a second antipsychotic medication. d. Assess the client for urinary retention.

d. Assess the client for urinary retention. Dying clients become agitated when they are in pain or have some discomfort. Before administering medications or other therapies to decrease discomfort, the nurse should assess for potential causes of discomfort including urinary retention.

The nurse is being trained in hospice care. Which intervention by the nurse is most compatible with the goals of end-of-life care for the client? a. Administer influenza and pneumococcal vaccinations. b. Prevent the client with chronic obstructive pulmonary disease from smoking. c. Perform passive range-of-motion exercises to prevent contractures. d. Permit the client with diabetes mellitus to have a serving of ice cream.

d. Permit the client with diabetes mellitus to have a serving of ice cream. When a client is near the end of life, nursing interventions should be focused toward facilitating peaceful death by granting the client's wishes and identifying his or her needs. Allowing a client who wishes to have something that is not permitted in the diet can be comforting if he or she has a craving or a desire for that food. There is no reason to withhold it at this time.