PRACTICE QUESTIONS EXAM 3 for 2900/2920
A patient with a burn injury is receiving IV Lactated Ringers 970mL/hr post 20 hours after a severe burn. The patients urinary output is 20mL/hr. As a nurse, the next nursing action you should do is... a. Call the provider b. Decrease the IV fluid rate c. Continue to monitor the patient d. Increase the IV fluid rate
A
Danielle, RN instructs her nursing assistant to obtain a daily weight. The nurse recognizes that this assessment is focused on which goal of client care? A. promotion of balanced nutrition B. infection prevention C. wound management D. coping
A
The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if the treatment was successful for this patient? A.The patients blood pressure changes from 75/48 to 110/82 B.Patients CVP 2mmHg C.Patients skin is warmed and flushed D.Patients urinary output 20mL/hr
A
What is a graft between members of the same species with different genotypes and HLA antigens? A. homograft B. Xenograft C. Autograft
A
You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? A. Airway patency B. Level of consciousness C. Blood pressure D. Pain level
A
A difference between a superficial partial thickness and full/deep partial thickness is: A. Full/deep partial thickness does not extend into papillary layer. B. Full/deep partial thickness extends into reticular layer and heals within month. C. Superficial partial thickness typically takes a month to heal. D. Superficial partial thickness extends into the reticular layer
B
A nurse is caring for a client hwo has burns to his face, ear and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. Urine output 25 ml/hr B. Difficulty swallowing C. HR 122/min D. Pain 6/10
B
A client with severe burns is receiving ranitidine hydrochloride (Zantac) 50 mg IV every 6 hours. What is the rationale for this therapy? A. Ongoing treatment for a client history of gastritis B. Management of moderate pain C. Prevention of Curling ulcers D. Vitamin supplementation
C
A healthcare provider admitted a client with second and third-degree burns over 60% of the body. Fourteen hours later, the client is receiving lactated Ringer's at 200 mL/hr. Which intervention is the priority at this time? A. Administer morphine sulfate PRN. B. Assess burned areas for signs and symptoms of infection. C. Monitor hourly urine output. D. Begin hourly range of motion
C
A nurse in the ED is reviewing the medical record of a client who had an extensive burn injury. Which lab result should the nurse expect? A. Metabolic alkalosis B. Hypervolemia C. Hyperkalemia D. Hypernatremia
C
A nurse in the PACU assess a client with endotracheal tube (ET) in place and observes left sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage by tongue B. Passage of ET tube into esophagus C. Movement of ET tube into right main bronchus. D. Infection of vocal cords.
C
A nurse is assessing a client with deep partial-thickness burns, what does it look like? A. Burned area is black and painless B. Burned area is pink with blisters C. Burned area is red with eschar D. Burned area is yellow with severe edema.
C
A nurse in the ER is caring for a client with 30% burn injury to lower extremities. Which of the following interventiosn should the nurse perform first? A. Clean and dress wound B. Administer pain meds C. Administer tetanus booster D. Administer IV fluids
D
A nurse is caring for a client who has a central venous cath and reports hearing a gurgling sound on side of cath insertion. Which of the following complications should the nurse suspect? A. Catheter occlusion B. Cath rupture C. Cath dislodgement D. Cath migration
D
A nurse is caring for a client who is expernecing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? A. Cryopripitates B. Platelets C. Albumin D. Packed RBCs
D
A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Decreased HR B. Dyspnea C. Increased BP D. Weak pulse
D
An adult client was severely burned in a grass fire resulting in second-degree burns on the left arm, left leg, and back as well as third-degree burns on the right arm. Using the rule of nines, the estimated extent of burns is: A. 27%. B. 36%. C. 45%. D. 54
D
The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select? A. Face tent B. Simple mask C. Nasal cannula D. Tracheostomy collar
D
Which of the following fluids is preferred to be administered in first 24 hrs following a burn injury? A. D5 in H20 B. D5 in NS C. NS D. LR
D
Which of the following is not an environmental factor in regard to burns? a. Smoking b. Occupation c. Drug and alcohol abuse d. High income
D
You are taking care of a patient with burn on right arm with small blisters, moist and red. This burn is: A. Eschar B. Full thickness C. Superficial D. Partial-thickness
D
A client is admitted with two of the SIRS variables: temperature 95 ℉ and WBC 14,000. Which intervention should the nurse initiate? A.Blood transfusion B.Broad-spectrum antibiotics C.NPO status D.Cooling bath
B
A patient presents with a burn that is pink and dry. They are in extreme pain. What type of burn is this? A. 1st degree B. 2nd C. 3rd D. 4th
A
A client comes into the ED with a partial-thickness burn on the back of their right leg. The burn area looks pink, blanched and is dry. What type of burn would this be? A. 1st Degree B.2nd Degree C. 3rd Degree D. 4th Degree
A
A nurse assessing a client determines he is in compensatory stage of shock. Which finding supports this conclusion? A. Confusion B. BP of 84/50 mmhg. C. Anuria D. Petechiae
A
A nurse has a spouse ask what a escharotomy is, how will you respond? A. Large incision made in eschar to improve circulation. B. Procedure involves client taking a shower and removing dead tissue. C. Piece of health skin removed from unburned area and grafted over burned area. D. Dead tissue will be nonsurgically removed
A
A nurse in ED cares for client with burns to head, neck and chest. What is the priority for assessment and intervention? A. Airway obstruction B. infection C. Fluid imbalance D. Paralytic ileus
A
A nurse in the ED is assessing a client with internal injuries from car crash. Client disoriented, diaphoretic, lips cyanotic. Which finding indicates hypovolemic shock? A. Increased HR B. Wide pulse pressure C. Increased deep tendon reflexes D. Pulse ox 96
A
A patient has sustained burns to the anterior head, front and back of right arm and back of left leg. What is TBSA with rule of nines? A. 22.5 B. 18 C. 18.5 D. 27
A
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
A
A patient has just been admitted to the ER with partial-thickness burns on the front of their neck/torso. You will... A. Raise head of bed B. Obtain IV access C. Restrict fluids D. Place pillow under pt's neck
A, B
Functions of the skin include: A. Prevention of loss of fluid B. Protection and sensation C. Temp regulation D. Vit D synthesis
A, B, C, D
You are providing care to four patients. Select ALL of the patients who are at risk for developing sepsis. A. 36-year-old female who is hospitalized with renal insufficiency and has a foley catheter and a central line B. 55-year-old male who recently received a kidney transplant C. 78-year-old female with diabetes mellitus who is recovering from colon surgery D. 65-year-old male recovering from right lobectomy for treatment of breast cancer
A, B, C, D. ALL.
A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? ( select all that apply) a) Limit visitors in the client's room. b) Encourage fresh vegetables in the diet. c) Increase protein intake. d) Instruct the client to consume 1,000 calories/day. e) Restrict fresh flowers in the room
A, C, E
Which of the following are complications of partial thickness burns (select all that apply)? a. Increased nutritional requirements. b. Vision loss. c. Confusion. d. Muscle soreness. e. Renal insufficiency
A, C, E
What are some of the patient priorities during the Acute/Intermediate phase of burn management? Select all that apply. a. Wound Closure b. Psychosocial Support c. Fluid Volume d. Nutrition e. Respiratory Status
A, D
A nurse is doing purposeful rounding of his patients. The next patient that he will be assessing has full thickness burns across the anterior and posterior surfaces of her right leg. What is the priority for this nurse? a) Turn the patient every two hours to prevent pressure ulcers. b) Wash hands with soap and water when entering the patient's room. c) Take a set of vital signs to assess her perfusion and fluid status. d) Administer her prescribed tetanus vaccine
B
A nurse is monitoring a client with severe burn injury and receiving IV fluids resuctation therapy. Nurse identify a decrease in what is an indication of adequate fluid replacement? A. BP B. HR C. Urine output D. weight
B
A nurse is reviewing a clients lab results and finding the hemoglobin 10 g/dl and hematocrit is 30%. the nurse recognizes that the client is at risk for which of the following? A. Prolonged bleeding B. Cell hypoxia C. Impaired immunity D. Fluid retention
B
A patient is diagnosed with septic shock. As the nurse you know this is a _____ form of shock. In addition, you're aware that ______ and _____ are also this form of shock. A.Obstructive; hypovolemic and neurogenic B.Distributive; anaphylactic and neurogenic C.Obstructive; cardiogenic and neurogenic D.Distributive; anaphylactic and cardiogenic
B
A patient weighs 125 kg and has sustained a 30% tbsa. Using parkland formula, how much volume will you give in first 8 hrS? A. 15 L B. 7.5 L C. 1500 ml D. 750 ml
B
What does TBSA stand for? a. The Body's Superficial Affect b. Total Body Surface Area c. Total Body Systemic Area d. The Burn Saving Association
B
What is skin transplanted from an animal (pig) vs patients healthy skin used to cover wound area? A. Animal: homograft, patient skin: xenograft B. Animal: xenograft, patient skin: autograft C. Animal: xenograft, patient skin: homograft D. Animal: autograft, patient skin: xenograft
B
What is the classification for partial thickness burns? a. 1st degree b. 2nd c. 3rd d. 4th
B
What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy? A. A client has a respiratory rate of 10 breaths per minute B. A client requires permanent ventilation C. A client exhibits symptoms of dyspnea D. A client has respiratory acidosis
B
The nurse is assessing a patient with N/V, headache, dizziness, and somnolence. The patient reports that she smoke in her old home and uses a portable heater. The nurse is suspecting Carbon Monoxide poisoning. What are causes to this occurrence? (Select all that apply) a) Many do not recognize CO poisoning until it starts to smell and by then it is too late b) Hemoglobin has a greater affinity to CO than O2 c) Living in an old home may suggest lack of carbon monoxide detectors d) Portable heaters are one of the leading causes of CO poison e) Smokers have an increased level of CO in blood
B, C, D, E
The nurse is caring for a client with suspected SIRS. Which clinical manifestations would this client present with? (select all that apply) Temperature of 100.0 ℉ Heart rate: 108 bpm White blood cells: 15,000 cells/mm3 Respiratory rate: 23 bpm Chills and night sweats
B, C, D, E
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse take to reduce risk for ventilator associated pneumonia? A. Position the head of the clients bed in the flat position. B. Turn the client every 4 hr C. Rinse the client's mouth with an antimicrobial solution every 4 hr. D. Perform hand hygiene prior to suctioning the clients endotracheal tube
C
A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which lab value should indicate to nurse that client is responding to tx? A. Na 165 B. K 5.2 C. Urine specific gravity 1.020 D. Hct 62
C
A nurse is caring for a client who is unconscious and has a breathing pattern charactertized by alternating periods of hyperventilation and apnea. Nurse document they have which RR pattern? A. Kussmaul B. Apneustic respirations C. Cheynne stokes D. Stridor
C
A nurse is caring for a toddler in ED with burns to lower legs. Which action should nurse take first? A. Apply ice to burns B. Place the child in a tub of cool water. C. Pour tepid water over the burns D. Cover the burns with a blanket
C
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A. DIC is controllable with lifelong heparin usage. B. DIC is characterized by an elevated platelet count. C. DIC is caused by abnormal coagulation involving fibrinogen. D. DIC is a genetic disorder involving a vitamin K deficiency.
C
A patient arrives in the emergency department with burn injuries. The patient's burn covers the face and the right forearm. What percentage of burn does the patient have? a) 27% b) 9% c) 18% d) 10
C
A patient has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning? A. Obturator B. Outer cannula C. Inner cannula D. Cuff
C
A patient has just experienced partial-thickness burns to their abdomen and left leg. What nursing dx is more important? A. Impaired skin integrity B. Risk for fluid volume overload C. Risk for infection D. Impaired mobility
C
Fluid Resuscitation calculations are based off of when? A. Arrival to ED B. ASAP C. Time of injury D. When patient exhibits s/s
C
Using the Rule of Nines, someone with a burn on their neck, front and back of the right leg would be what percent? A. 9 B. 18 C. 27 D. 36
C
Which patient below is at the MOST risk for developing ARDS? 55-year-old male with a pneumothorax 46-year-old being treated for diabetic ketoacidosis 70-year-old female with sepsis cause by gram-negative bacterial infection 32-year-old female with cystic fibrosis
C
As the nurse you know that ARDS can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS A.Drowning B.Aspiration C.Sepsis D.Blood transfusion E.Pneumonia F.Pancreatitis
C, D, F...Causes outside of lungs.
A 45 year old male patient has superficial partial-thickness burns to the anterior head and neck, anterior left arm, and posterior right leg. Using Rule of Nines, calculate the total body surface area percentage that is burned? a. 36% b. 9% c. 27% d. 18% e. 14.5
D
A client has a right subclavian central venous catheter. When reconnecting a new admin set, which instructions should the nurse give the client? A. Exhale slowly B. Turn head to the right C. Sit in semi fowlers D. Bear down while holding breath.
D
The only way to determine the extent of burns is TBSA. A. True B. False
False
You should apply ice to a thermal burn? A. True B. False
False
Carbon monoxide has a 200 times greater affinity for hemoglobin when compared to oxygen? True or false
True
