Nursing Care of Adult, Test 3
A patient has been admitted in septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to find to support this diagnosis?
Cardiac output (CO) of 8 L/min
A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. The nurse suspects the patient may have which type of injury?
Central cord syndrome
The nurse is caring for a patient with an upper gastrointestinal bleed. What procedure would the nurse expect the practitioner to order to confirm this diagnosis?
Endoscopy
A patient was admitted with pancreatitis. In which order would the nurse perform an assessment of the gastrointestinal system?
Inspection, auscultation, percussion, and palpation
A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason?
Lack of blood supply
A patient was admitted with liver failure and acute kidney injury (AKI). Which intravenous solution should the nurse question if it was ordered for this patient?
Lactated Ringer solution
The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient?
Lactulose
A patient has been admitted with a flail chest. What findings would the nurse expect to observe supporting this diagnosis?
Paradoxical respiratory movement
What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn?
Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space.
A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs as a result of what pathophysiologic mechanism?
Premature activation of inactive digestive enzymes, resulting in autodigestion
Which topical antimicrobial agent is commonly used as a broad-spectrum agent and is activated by the wound moisture?
Silver
A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery?
Small doses of intravenous opioids titrated to effect
A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock?
Spinal cord injury
Preprocedural teaching of a patient undergoing a liver scan should include which instruction?
Stay flat and still during the procedure.
What is the most common site for short-term vascular access for immediate hemodialysis?
Subclavian vein
Hospice care is an option that should be considered, especially in end-stage illness. Hospice care can help families with which issue(s)?
Symptom management and family support
Sickle cell anemia is the most prevalent in persons of which descent?
West African
Recommendations for creating a supportive atmosphere during end-of-life discussions include which intervention?
Beginning the conversation by inquiring about the emotional state of the family
The practitioner has ordered continuous renal replacement therapy (CRRT) for a patient with acute kidney injury. The patient needs both the removal of fluids and a moderate amount of solutes. Which type of CRRT would the nurse anticipate being started on this patient?
Continuous venovenous hemofiltration (CVVH)
A patient has been admitted with acute kidney injury. The nurse knows the most important consideration for evaluating the patient's fluid status is what parameter?
Daily weights
The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to find to support this diagnosis?
Decreased cardiac index
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to find to support this diagnosis?
Decreased platelet counts
A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record?
Deep dermal partial-thickness burn
The nurse is caring for a critically ill patient who is receiving heparin and understands that the patient is at risk for developing heparin-induced thrombocytopenia (HIT). Which previous medical conditions places this patient at risk for developing HIT?
Deep vein thrombosis
A patient is being admitted in cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient?
Epinephrine
A patient with known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administered first?
Epinephrine
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC?
Excessive thrombosis and fibrinolysis
A patient was admitted to the critical care unit after having a CVA and MI. The patient has poor activity tolerance, falls in and out of consciousness, and has poor verbal skills. The patient has been resuscitated four times in the past 6 hours. The patient does not have advance directives. Family members are at the bedside. Who should the practitioner approach to discuss decisions of care and possible DNR status?
Family
A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodiafiltration (CVVHDF). The nurse understands the patient should be closely monitored for what circuit-related complications of the therapy?
Filter clotting, access failure, and air embolism
A patient has been admitted in septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention?
Finding and eradicating the cause of infection
The nurse has been caring for a patient with a liver abscess. Upon auscultation of the right upper quadrant, the nurse would expect to hear which type of sounds?
Friction rub
A patient was admitted with an infection that had to be treated with an aminoglycoside antibiotic. After few days, the patient developed oliguria and elevated blood urea nitrogen and creatinine levels. The patient's vital signs are stable. The nurse would anticipate the practitioner ordering which dialysis method for this patient?
Hemodialysis
A patient with chronic kidney disease was admitted with severe electrolytes disturbances. The patient had been ill and missed several hemodialysis sessions. The patient is disoriented, dizzy, cold, clammy, and complains of severe abdominal cramping. The patient's electrocardiogram appears normal. Which electrolyte disturbance would the nurse suspect the patient may be experiencing?
Hyponatremia
A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan?
IV rate should be increased and fluid status closely watched.
The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem?
Inability of the heart to pump blood forward
A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse understands the patient should be closely monitored for what patient-related complications of the therapy?
Infection, hypotension, and electrolyte imbalances
A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid?
Inserting a large-diameter peripheral intravenous catheter
A patient is being admitted from the emergency department (ED) in cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit?
Insertion of an intra-aortic balloon pump (IABP)
The practitioner has ordered dialysis for a patient with acute heart failure who is unresponsive to diuretics. Which type of dialysis would the nurse anticipate being started on this patient?
Intermittent ultrafiltration
A patient is admitted in acute heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. Which diagnostic tests would provide the best information about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder?
Intravenous pyelography (IVP)
A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to find to support this diagnosis?
Jaundice
What intervention should be included in the patient management plan of a patient undergoing an angiogram?
Keep the affected extremity straight and immobilized for 6 to 12 hours after the procedure.
Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related to what physiologic change?
Limited physiologic reserve
A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process?
Loss of sympathetic nervous system innervation
The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention would have the highest priority?
Managing pain
A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse understands that this type of continuous renal replacement therapy (CRRT) is indicated for the patient who needs what type of treatment?
Maximum fluid and solute removal
A patient has sustained an epidural hematoma after a 10-foot fall from a roof. The nurse understands that an epidural hematoma is a condition that has which characteristic?
Most often associated with middle meningeal artery lacerations
In caring for a patient receiving palliative care, antiemetics are used in the treatment of what problem?
Nausea and vomiting
The nurse is working on an organization-wide falls prevention project. The nurse understands that the majority of falls accounting for traumatic injury occur in what population?
Older adults
The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which type of trauma is this complication usually associated with?
Orthopedic trauma
A patient has been on complete bed rest for 3 days. The practitioner has left orders to get the patient out of bed for meals. The patient complains of feeling dizzy and faint while sitting at the bedside. The nurse suspects that the patient is experiencing what problem?
Orthostatic hypotension
A patient was admitted with acute heart failure who has been receiving diuretic therapy. The nurse suspects the patient is hypovolemic. What auscultatory parameter would confirm the nurse's suspicion?
Orthostatic hypotension
Which form is considered medical orders and is honored across all treatment settings and are especially important to emergency responders in the community?
POLST
A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record?
Partial-thickness (second-degree) burn
Patient has been admitted who is severely malnourished. The patient's serum albumin is very low. Which finding would the nurse expect to see in this patient?
Peripheral edema
A patient has been admitted in anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism?
Peripheral vasodilation
While palpating a patient's abdomen, the nurse observes the presence of persistent involuntary guarding despite efforts to get the patient to relax. This finding is indicative of which condition?
Peritoneal inflammation
A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism?
Portal hypertension
A patient is admitted with acute kidney injury (AKI). Which event from the patient's history was the most probable cause of the patient's AKI?
Recent computed tomography of the brain with and without contrast
A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury?
Rhabdomyolysis
The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called?
Sepsis
A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information?
Shock is an acute wide spread process of inadequate tissue perfusion.
A patient is admitted with symptoms of a low-grade fever, joint pain, tachycardia, hepatomegaly, photophobia, and an inability to follow commands. The patient is becoming more agitated and complaining of pain. The nurse suspects that the patient has which disorder?
Sickle cell anemia
The practitioner has ordered a test for steatorrhea. The nurse knows this is determined by which laboratory study?
Stool studies
The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence?
Subcutaneous emphysema
A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center?
The medical history of the patient and the size and depth of the burn injury
A patient is admitted with sepsis and acute kidney injury (AKI). The patient is started on continuous renal replacement therapy (CRRT). The nurse knows that fluid is removed each hour is charted as what on the CRRT flow sheet?
Ultrafiltrate
To remove fluid during hemodialysis, a positive hydrostatic pressure is applied to the blood and a negative hydrostatic pressure is applied to the dialysate bath. What is this process called?
Ultrafiltration
A patient has been admitted with abdominal pain. The practitioner suspects the patient has gallstones. Which diagnostic procedure would the nurse expect the practitioner to order to confirm this diagnosis?
Ultrasonography
The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage?
Zone of coagulation
A patient with severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize secondary brain injury?
Administer fluids to keep the mean arterial pressure greater than 60 mm Hg.
The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient?
Administer sodium bicarbonate to keep arterial pH greater than 7.20.
A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock?
Bacterial toxins lead to vasodilation.
The nurse has been caring for a patient with severe pancreatitis. The practitioner suspects the patient has developed a pseudocyst. Which diagnostic procedure would the nurse expect the practitioner to order to confirm this diagnosis?
CT of abdomen
A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. The nurse would monitor the patient for which side effect of the medication?
Chest pain
Which pathophysiologic events contributes to renal failure associated with tumor lysis syndrome?
Crystallization of uric acid in the renal tubules
A patient was admitted with gram-negative sepsis a few days ago. Today the nurse observes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. What other laboratory value would be valuable in definitively diagnosing the patient's condition?
D-Dimer level
Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action?
Daily assessment for proper fit and effectiveness
The nursing management plan for a patient with full-thickness burns includes which intervention?
Daily wound care with premedication
Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem?
Decreased pulmonary compliance
Haloperidol has traditionally been used to manage which symptom?
Delirium
A patient has been admitted with tumor lysis syndrome. The nurse understands that this is due which pathophysiologic mechanism?
Destruction of malignant cells through radiation or chemotherapy
The patient's condition has deteriorated to the point where she can no longer make decisions about her own care. Which nursing interventions would be most appropriate?
Discuss with the family what the patient's wishes would be if she could make those decisions herself.
The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse knows that pulmonary embolism is a serious complication of HIT. Which findings would alert the nurse to the presence of this complication?
Dyspnea, pleuritic pain, and rales
Which statement about comfort care is accurate?
Each procedure should be evaluated for its effect on the patient's comfort before being implemented.
In a patient with a distended abdomen differentiating ascites from solid bowel contents is accomplished by performing what assessment?
Eliciting a fluid wave
A patient is admitted with acute abdominal trauma. The patient has a positive Focused Assessment with Sonography for Trauma (FAST scan) and is hemodynamically unstable. What procedure should the nurse anticipate next?
Emergency surgery
Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage?
Ensuring the patient has a patent airway
A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next?
Escharotomy
The practitioner has ordered a magnetic resonance imaging (MRI) of the liver. What would the nurse do to prepare the patient for the examination?
Explain the patient must lie still during the procedure.
One therapeutic measure for treating hyperkalemia is the administration of dextrose and regular insulin. Which description regarding how this treatment works is accurate?
Forces potassium out of the serum into the cells.
The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse understands that this disorder has which characteristic?
Formation of thrombi
A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock?
Hypoperfusion results in loss of gut barrier function.
What is the most common complaint heard from families of dying patients?
Inadequate communication
A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient is placed on a morphine drip to alleviate suspected operative pain and assist in sedation. The patient continues to grimace and fight the ventilator. What nursing intervention would be appropriate?
Increase the morphine dosage until no signs of pain or discomfort are present.
A patient has been admitted with a pulmonary contusion. Which finding will cause a nurse to suspect that the patient's condition is deteriorating?
Increased work of breathing
A patient was admitted with an infection that had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, the patient developed oliguria, and an elevated blood urea nitrogen and creatinine levels. The nurse suspects the patient has developed what type of kidney injury?
Intrarenal
A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase?
Intravenous opiates and assessment of pulses in both arms
A patient has been admitted with sickle cell anemia and is requiring a blood transfusion. The nurse understands that transfusions should be used with caution in this patient because of what complication?
Iron overload
A patient was admitted with gram-negative sepsis a few days ago. Today the nurse notes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. The nurse places highest priority on which treatment goal?
Maintain adequate organ perfusion.
A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor vehicle crash. The patient's plan of care would involve which nursing action?
Monitor blood pressure and temperature every hour.
The nurse is caring for a critically ill patient who is receiving heparin and understands that the patient is at risk for developing heparin-induced thrombocytopenia (HIT). Which intervention would be included into the patient's plan of care to monitor for this potential complication?
Monitor platelet count every 2 or 3 days from day 4 to day 14.
A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care?
Monitor the patient for hypovolemic shock from plasma volume depletion.
A patient is admitted with a blunt cardiac injury (BCI) with no evidence of rupture. The nursing management plan should include which intervention?
Monitor the patient for new onset dysrhythmias.
The nurse is caring for a patient who was just admitted in septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order?
Obtain a serum lactate level.
A nurse and a new graduate nurse are discussing the secondary survey of the trauma patient. The nurse asks the new graduate to identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the information?
Obtain patient history.
To assess whether or not an arteriovenous fistula is functioning, what must the nurse do and why?
Palpate gently over the site of the fistula to determine whether a thrill is present; listen with a stethoscope over this site to appreciate a bruit to assess the quality of the blood flow.
A patient was admitted with an abdominal mass. Which assessment technique would the nurse find most useful in detecting this pathologic condition?
Palpation
A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing which is characterized by rapid synthesis of collagen. What phase is the patient in?
Proliferative phase
A patient has been admitted in acute heart failure. Which parameter would indicate to the nurse that the patient is fluid overloaded?
Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg
A patient has been admitted in anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE) mediated response as a result of what physiologic mechanism?
Repeat exposure to an antigen in the presence of preformed IgE antibodies
A patient with multisystem trauma has been in the ICU for 6 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include: BP—92/66 mm Hg; HR—118 beats/min; T—38.7°C; and CVP—5 mm Hg. What is the most likely cause of this hemodynamic picture?
Septic shock
A patient has developed acute kidney injury (AKI) secondary to cardiogenic shock. Which laboratory value would the nurse find helpful in evaluating patient's renal status?
Serum creatinine
When calculating the anion gap, what is the predominant cation?
Sodium
A patient was admitted with acute kidney injury. Which urinalysis value reflects a decreased ability of the kidneys to concentrate urine?
Specific gravity of 1.000
A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse suspects these findings are indicative of which disorder?
Tension pneumothorax
A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The decision is made to remove the patient from the ventilator. Which statement is most accurate?
The family and health care team should decide the best method for removing the ventilator: terminal wean versus immediate extubation.
A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted a chest tube on the left side and 1800 mL of blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure?
Thoracotomy
The nurse is caring for a patient with gastrointestinal bleeding. The practitioner was unable to locate the bleed with an endoscopy. Which procedure would the nurse expect the practitioner to order next?
Angiogram
An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate?
Airway assessment must incorporate cervical spine immobilization.
A patient is undergoing a hepatobiliary scan to assess the progression of cirrhosis of the liver. The nurse would anticipate which result?
Little or no uptake
A patient has been admitted in hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis?
Decreased level of consciousness
What is the recommended nutritional intake of protein to control azotemia in the patient with acute kidney injury?
1.2 to 1.5 g/kg/day
A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage?
Peptic ulcers
A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery is a RYGBP. What would be an appropriate response from the nurse?
"It is a combination of restrictive and malabsorption types of bariatric surgery.
A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What would be an appropriate response from the nurse?
"This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction."
A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient does not have an advance directive. Which statement would be the best way to approach the family regarding his ongoing care?
"What would the patient want if he knew he were in this situation?"
A patient was admitted with acute heart failure. The nurse is assessing the patient for peripheral edema. The nurse presses two fingers over the tibial area, and it takes 1 minute before the indention disappears. What would the nurse in the medical record?
+3 pitting edema
Place these pathophysiologic mechanisms of DIC in the order in which they occur.
1. Endothelial damage; release of tissue factor 2. Thrombin formation; clots form along epithelial walls 3. Consumption of coagulation factors; failure of regulatory mechanisms 4. Activation of the fibrinolytic system 5. Breakdown of thrombi; spontaneous hemorrhage
Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial- and full-thickness burns to half of his left arm, his entire left leg, and his perineum.
23.5%
A patient is admitted with acute kidney injury. The patient's weight upon admission was 176 lb and the next day it is 184 lb. What is the approximate amount of fluid retained with this weight gain?
3600 mL
The nurse is developing a patient education plan for the patient with sickle cell anemia. Hydroxyurea is the medication used in the treatment of the disorder. The nurse would inform the patient that the hydroxyurea may be increased by what dosage until the maximum of 35 mg/kg is reached?
5 mg/kg every 12 weeks
A patient was admitted with pancreatitis. The nurse is auscultating the patient's abdomen. How long must the nurse listen to be able to accurately chart that bowel sounds are absent?
5 minutes
Using the Parkland formula for fluid resuscitation and knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg.
5550 mL
A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement?
5950 mL of Lactated Ringer solution (LR) for the first 8 hours; then 5950 mL of LR over the next 16 hours
An elderly patient is in a motor vehicle accident and sustains a significant internal hemorrhage. The nurse knows the patient is at risk for developing what type of acute kidney injury (AKI)?
Prerenal
The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called?
Absolute hypovolemia
A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next?
Administer 100% oxygen via a nonrebreathing mask.
A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control?
Administer analgesics around the clock.
The nurse is caring for a patient with acute liver failure. What laboratory value would the nurse expect to decrease in this situation?
Albumin
A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan?
Alcohol cessation
A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. After a family conference, the practitioner writes a DNR order, and palliative care is begun. How does this affect the patient's treatment?
All attempts will be made to keep the patient comfortable without prolonging his life.
A patient was admitted with pancreatitis. Which laboratory value would the nurse expect the practitioner to order to confirm this diagnosis?
Amylase
Upon auscultation, the nurse hears borborygmi. The nurse suspects the patient may be developing which problem?
An intestinal obstruction
As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release of what substance?
Antidiuretic hormone
A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority?
Assess the airway and provide 100% oxygen.
A patient was admitted with multiple trauma who has been volume resuscitated. The nurse suspects the patient is fluid overloaded. Which assessment findings would confirm the nurse's suspicion?
Presence of a third heart sound
Percussion of kidneys is usually done to assess what parameter?
Presence of pain in the renal area
A patient is admitted to the ICU for observation of his grade II splenic laceration. Which signs and symptoms suggest that the patient has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock?
BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused
A nursing instructor is discussing the difference between primary and secondary multiple organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information?
Primary MODS is the result of a direct organ injury.
The nurse is caring for a patient with acute liver failure. The practitioner asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom?
Have the patient extend the arms and dorsiflex the wrists.
What is the most common cause of disseminated intravascular coagulation (DIC)?
Sepsis caused by gram-negative organisms
A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable what cause?
Under-resuscitation because of probable wound conversion.
The patient complains of a metallic taste and loss of appetite. The nurse is concerned that the patient has developed what problem?
Uremia
A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information?
Used to assess level of consciousness
A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the practitioner to order for this patient?
Vasopressin
A patient with multisystem trauma has been in the critical care unit for 2 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication?
Venous thromboembolism
The nurse is assessing a patient with abdominal pain. Which finding should be reported to the practitioner?
Visible peristaltic waves
A patient was admitted with acute heart failure a few days ago. Today the patient's urine has a specific gravity of 1.040. What could be the potential cause for this value?
Volume deficit
A patient is admitted in acute kidney injury. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. The nurse suspects the main cause of ascites is what condition?
Volume overload
A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms?
Hematemesis and melena
The nurse has been caring for a patient with liver dysfunction. The practitioner has just performed a liver biopsy at the bedside. Following a liver biopsy, how would the nurse position the patient?
Right side for 2 hours
The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information?
"Autografts provide permanent coverage and are the least expensive."
A trauma patient's condition has deteriorated. The nurse observes changes in the patient's condition including trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication?
Hemothorax
A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen?
Prevents tube from adhering to the gastric wall.
What is a leading cause of death in the hospitalized burn patient?
Smoke inhalation
