Urden Questions CBA 5

A patient is admitted to the intensive care unit (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? a. Blood pressure (BP), 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/h; skin that is pink, warm, and dry, with capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/h; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/h; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/h; flushed, warm, diaphoretic skin; agitated and confused

ANS: B The first set of vital signs is normal. Patients who are in hemorrhagic shock are significantly tachycardic with a narrowed pulse pressure and oliguric, and their skin is pale, cool, and clammy. They also have a low hematocrit and are confused. Hemodynamically stable patients may be monitored in the critical care unit by means of serial hematocrit values and vital signs. Progressive deterioration may indicate the need for operative management.

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? a. Ischemic stroke b. Spinal cord injury c. Guillain-Barré syndrome d. Brain tumor

ANS: B The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.

A patient is admitted with a blunt cardiac injury (BCI) with no evidence of rupture. The nursing management plan should include which intervention? a. Administer nitroglycerine for chest pain as needed. b. Monitor the patient for new onset dysrhythmias. c. Monitor serial biomarkers for evidence of further damage. d. Do not administer antidysrhythmic medications, as they are ineffective.

ANS: B The patient should be monitored for new onset of dysrhythmias. The patient may complain of chest pain that is similar to anginal pain, but it is not typically relieved with nitroglycerin. Chest pain is usually caused by associated injuries. Use of biomarkers, such as troponin, offers very little diagnostic help for blunt cardiac injury (BCI). Medical management is aimed at preventing and treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of antidysrhythmic medications.

What is the primary mechanism in the development of tumor lysis syndrome? a. Destruction of platelets by lymphocytic antibodies b. Destruction of malignant cells through radiation or chemotherapy c. Formation of heparin antibodies d. Damage to the endothelium

ANS: B The primary mechanism involved in the development of tumor lysis syndrome is the destruction of massive numbers of malignant cells, either by chemotherapy or radiation. This mass destruction results in the release of large amounts of potassium, phosphorus, and nucleic acids, leading to severe metabolic disturbances such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.

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? a. Fluid overload b. Iron overload c. Vasoocclusive crisis d. Stroke

ANS: B Transfusion therapy is used with extreme caution due to risks such as iron overload, exposure to hepatitis, HIV and other infectious agents, alloimmunization, induction of hyperviscosity, and limitations on resources. The indications for having a blood transfusion or exchange are recurrent painful vasoocclusive crises with long hospital admissions, acute chest syndrome, stroke, priapism, and leg ulcers.

A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. Warm, dry skin b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure e. Decreased pulmonary artery occlusion pressure

ANS: B, C, D Clinical manifestations of cardiogenic shock include heart rate greater than 100 beats/min; cool, pale, moist skin; weak, thready pulse; and increased right atrial pressure and pulmonary artery occlusion pressure.

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? a. Idiopathic thrombocytopenic purpura b. Heparin-induced thrombocytopenia c. Sickle cell anemia d. Disseminated intravascular coagulation

ANS: C A variety of clinical manifestations are associated with sickle cell anemia. The patient may present with a low-grade fever, bone or joint pain, pinpoint pupils, inability to follow commands, photophobia, tachycardia, tachypnea, decreased respiratory excursion, hepatomegaly, nonpalpable spleen, and pretibial ulcers.

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 note to support this diagnosis? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase

ANS: C Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult. Jaundice and transient elevations in serum transaminase and bilirubin levels occur. Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of bilirubin from hemoglobin catabolism.

The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to prevent cross-contamination and decrease the risk of infection in the burn-injured patient? a. Gloves are the only personal protective equipment worn when changing dressings that are in direct contact of body fluids. b. Family members only have to wear a gown when visiting a patient because masks will increase anxiety in the patient. c. Changing gloves and handwashing should be done when moving from area to area on the same patient. d. Sharing of equipment between patients in the same room does not show evidence of cross-contamination.

ANS: C Cross-contamination by direct contact is a significant source of infection and a subsequent cause of sepsis. Effective handwashing technique cannot be overemphasized. Nurses must wash their hands and change gloves when moving from area to area on the same patient. For example, after changing the chest dressing, which may be contaminated with sputum from the tracheostomy, hands must be washed and gloves changed before the nurse moves to the legs. Gowns, gloves, and masks should be worn whenever contact with body fluids occurs. These garments also must be changed and hands washed before caring for a different patient. Maintaining patient-specific dressings and topical agents is recommended. Equipment such as thermometers, intravenous pumps, and stethoscopes should be designated for each patient or, when shared, should be cleaned with appropriate bactericidal cleansers between patients.

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? a. Monitor D-dimer levels every 5 to 10 hours from day 2 to day 5. b. Monitor prothrombin time (PT) every 5 to 14 hours from day 2 to day 12. c. Monitor platelet count every 2 or 3 days from day 4 to day 14. d. Monitor international normalized ratio (INR) every 5 days from day 10 to day 30.

ANS: C Current guidelines suggest that for high-risk patients, platelet count monitoring should be performed every 2 or 3 days from day 4 to day 14. When a decrease in the platelet count is detected, heparin therapy should be discontinued immediately, and the patient should be tested for the presence of heparin antibodies.

The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which group of patients is a high risk for this complication? a. Patients with liver trauma b. Patients with burns c. Patients with orthopedic trauma d. Patients with spleen trauma

ANS: C Fat embolism syndrome can occur as a complication of orthopedic trauma.

Hospital-acquired anemia is an increasing problem in critically ill patients. Which nursing interventions can be most beneficial in preventing this problem? a. Administering fluids and inotropic agents to optimize blood pressure b. Using blood salvage devices c. Obtaining smaller blood samples through the use of pediatric blood tubes and point-of-care testing d. Decreasing afterload through the use of vasodilators

ANS: C Frequent blood draws in critically ill patients have been associated with the development of anemia. Blood losses correspond to actual volume of samples and discards when drawing from venous access lines. Critical care nurses can be instrumental in significantly decreasing blood loss in this arena. The use of pediatric collection tubes and point-of-care testing are techniques that yield valid diagnostic results but require smaller amounts of blood.

A patient has been admitted with 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? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE antibodies d. Activation of the systemic inflammatory response

ANS: C Immunoglobulin E (IgE) is an antibody that is formed as part of the immune response. The first time an antigen enters the body, an antibody IgE, specific for the antigen, is formed. The antigen-specific IgE antibody is then stored by attachment to mast cells and basophils. This initial contact with the antigen is known as a primary immune response. The next time the antigen enters the body, the preformed IgE antibody reacts with it, and a secondary immune response occurs.

A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. Epinephrine b. Nitroprusside c. Dobutamine d. Nitroglycerine

ANS: C Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice. A vasopressor, preferably norepinephrine (not Epinephrine), may be necessary to maintain blood pressure when hypotension is severe. Diuretics may be used for preload reduction. Vasodilating agents (Nitroglycerine and Nitroprusside) are used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer in shock.

A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels

ANS: C Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of disseminated intravascular coagulation (DIC). DIC does not affect serum glucose levels.

A patient is being admitted from the emergency department (ED) with 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? a. Administration of sodium bicarbonate b. Rapid infusion of crystalloids c. Insertion of an intraaortic balloon pump (IABP) d. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)

ANS: C Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an intraaortic balloon pump (IABP), a percutaneous ventricular assist device (VAD), or an extracorporeal membrane oxygenator. The IABP is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. It achieves this goal by improving coronary artery perfusion and reducing left ventricular afterload. Sodium bicarbonate, fluids, and dialysis are not indicated in this situation.

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? a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.

ANS: C Negative interstitial hydrostatic pressure represents an edema-generating mechanism and occurs for approximately 2 hours after injury. Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space. Plasma is then further diluted with fluid resuscitation. Thus osmotic pressure is decreased and further fluid extravasation can occur.

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? a. Construction workers b. Adolescents c. Older adults d. Young adults

ANS: C Older persons experience most of the falls that result in injuries, and these falls are likely to occur from level surfaces or steps. Because many of the falls may be caused by an underlying medical condition (eg, syncope, myocardial infarction, dysrhythmias), management of an older patient who has fallen must include an evaluation of events and conditions immediately preceding the fall.

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? a. Perform neurologic assessments once a shift. b. Obtain a computed tomography (CT) scan every day. c. Monitor blood pressure and temperature every hour. d. Initiate warming measures to keep temperature greater than 37.5° C.

ANS: C Severe diffuse axonal injury (DAI) usually manifests as a prolonged, deep coma with periods of hypertension, hyperthermia, and excessive sweating. Treatment of DAI includes support of vital functions. The outcome after severe DAI is poor because of the extensive dysfunction of cerebral pathways. Neurologic assessment is performed every hours. DAI may not be visible on computed tomography (CT) scan. Warming measures are generally not needed, but cooling measure may be needed.

The nurse is developing a patient education plan for a 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? a. 5 mg/kg every 4 weeks b. 10 mg/kg every 8 weeks c. 5 mg/kg every 12 weeks d. 15 mg/kg every 15 weeks

ANS: C The patient is usually started at a dose of 15 mg/kg by mouth once a day. The dose is increased by 5 mg/kg every 12 weeks until 35 mg/kg is reached as long as the patient's blood count remains within an acceptable range.

A patient has been admitted with a flail chest. What findings would the nurse expect to note supporting this diagnosis? a. Tracheal deviation toward the unaffected side b. Jugular venous distention c. Paradoxical respiratory movement d. Respiratory alkalosis

ANS: C Tracheal deviation and jugular venous distention are findings associated with tension pneumothorax. Respiratory acidosis is usually present because of the ineffective breathing pattern. In a flail chest, a free-floating segment of the chest wall moves independently from the rest of the thorax and results in paradoxical chest wall movement during the respiratory cycle. During inspiration, the intact portion of the chest wall expands while the injured part is sucked in. During expiration, the chest wall moves in, and the flail segment moves out.

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? a. Pneumonia b. Infection c. Venous thromboembolism d. Fat embolism syndrome

ANS: C Trauma patients are at risk for infection because of contaminated wounds, invasive therapeutic and diagnostic catheters, intubation and mechanical ventilation, host susceptibility, and the critical care environment. Nursing management must include interventions to decrease and eliminate the trauma patient's risk of infection.

The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury? a. Arachidonic acid metabolite b. Platelet-activating factor c. Tumor necrosis factor d. Interleukin

ANS: C Tumor necrosis factor-á (TNF-á, also known as cachectin) is a polypeptide that is released from macrophages and lymphocytes in response to endotoxin, tissue injury, viral agents, and interleukins. When present in excessive amounts, TNF-á causes widespread destruction in most organ systems and is responsible for the pathophysiologic changes in systemic inflammatory response syndrome (SIRS) and septic shock, including fever, hypotension, decreased organ perfusion, and increased capillary permeability.

The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called? a. Infectivity b. Anaphylaxis c. Sepsis d. Acute respiratory distress syndrome (ARDS)

ANS: C When systemic inflammatory response syndrome (SIRS) is the result of infection, it is referred to as sepsis.

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? a. Anorexia leads to loss of gastric enzymes b. Lack of food ingestion leads to intestinal hypomotility c. Hypoperfusion results in loss of gut barrier function d. Low cardiac output causes decreased hydrochloric acid secretion

ANS: C With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and multiple-organ dysfunction syndrome (MODS).

A patient has been admitted with tumor lysis syndrome (TLS). Which laboratory findings would the nurse expect to note to support this diagnosis? (Select all that apply.) a. Increased calcium b. Decreased potassium c. Dysrhythmias d. Elevated blood urea nitrogen (BUN) e. Elevated creatine

ANS: C, D, E Common laboratory findings in tumor lysis syndrome (TLS) are as follows: increased potassium, phosphorus, uric acid, blood urea nitrogen (BUN), and creatine; decreased calcium, creatinine clearance, pH, bicarbonate, and PaCO2.

A patient has been admitted with a flail chest and pulmonary contusion. Which finding will cause a nurse to suspect that the patient's condition is deteriorating? a. Increased bruising on the chest wall b. Increased need for pain medication c. The development of respiratory alkalosis d. Increased work of breathing

ANS: D A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. Patients with severe contusions may continue to show decompensation, such as respiratory acidosis and increased work of breathing, despite aggressive nursing management. Increased bruising and the need for pain medication are not signs of deterioration.

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? a. Autografts are procured from both live and deceased donors. b. Autografts can placed at the bedside or in the operating room. c. Autografts can transmit disease and be rejected. d. Autografts provide permanent coverage and are the least expensive.

ANS: D An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient's burn wound to provide permanent coverage of the wound. Autografts must be done in the operating room and are the least expensive. Homografts can transmit disease and be rejected.

The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support this diagnosis? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index

ANS: D Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2.

The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP). Which platelet count would the nurse expect to note to confirm this diagnosis? a. 28,000/mm3 b. 35,000/mm3 c. 72,000/mm3 d. 110,000/mm3

ANS: A A platelet count below 30,000/mm3 is indicative of idiopathic thrombocytopenic purpura (ITP).

A patient with a history of alcoholism is admitted with esophageal bleeding. Which finding would be an indication for the administration of blood in this patient? a. Hemoglobin less than 7 g/dL b. Hematocrit less than 30% c. Altered level of conscious d. D-dimer greater than 250 ng/mL

ANS: A A transfusion threshold of 7 g/dL or below, with a target hemoglobin (Hb) range of 7 to 9 g/dL, should be the default for all critically ill patients, unless specific comorbidities or acute illness-related factors modify clinical decision-making. Transfusion triggers should not exceed 9 g/dL in most critically ill patients. An altered level of conscious and an elevated D-dimer are not indications for transfusion.

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? a. Absolute hypovolemia b. Distributive hypovolemia c. Relative hypovolemia d. Compensatory hypovolemia

ANS: A Absolute hypovolemia occurs when there is a loss of fluid from the intravascular space. This can result from an external loss of fluid from the body or from internal shifting of fluid from the intravascular space to the extravascular space. Fluid shifts can result from a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure. Relative hypovolemia occurs when vasodilation produces an increase in vascular capacitance relative to circulating volume.

An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate? a. Airway assessment must incorporate cervical spine immobilization. b. Hyperextension of the neck is the only acceptable technique. c. Flexion of the neck protects the patients from further injury. d. Airway patency takes priority over cervical spine immobilization.

ANS: A Airway assessment must incorporate cervical spine immobilization. The patient's head should not be rotated, hyperflexed, or hyperextended to establish and maintain an airway. The cervical spine must be immobilized in all trauma patients until a cervical spinal cord injury has been definitively ruled out.

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? a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon occurs d. Suppression of the sympathetic nervous system

ANS: A Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.

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? a. Tension pneumothorax b. Cardiac tamponade c. Simple pneumothorax d. Ruptured diaphragm

ANS: A Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to the shoulders. Patients with cardiac tamponade will not have unilateral decreased breath sounds. Neither a simple pneumothorax nor a ruptured diaphragm will result in hypotension, jugular venous distention, or tracheal deviation unless it goes untreated.

Place these pathophysiologic mechanisms of disseminated intravascular coagulation (DIC) in the order in which they occur. 1. Activation of the fibrinolytic system 2. Breakdown of thrombi; spontaneous hemorrhage 3. Consumption of coagulation factors; failure of regulatory mechanisms 4. Endothelial damage; release of tissue factor 5. Thrombin formation; clots form along epithelial walls a. 4, 5, 3, 1, 2 b. 4, 1, 3, 2, 5 c. 5, 1, 2, 4, 3 d. 2, 3, 1, 5, 4

ANS: A Endothelial damage triggers the release of tissue factor. Thrombin is released, and clots form, consuming coagulation factors. The fibrinolytic system is triggered to break down the clots, which leads to spontaneous hemorrhage.

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? a. Usually arterial in nature b. Worse mortality rate than subdural hematomas c. Associated with a permanent loss of consciousness d. Signs and symptoms include bilateral pupil dilation

ANS: A Epidural hematoma (EDH) is a collection of blood between the inner table of the skull and the outermost layer of the dura. EDHs are most often associated with skull fractures and middle meningeal artery lacerations (two thirds of patients). A blow to the head that causes a linear skull fracture on the lateral surface of the head may tear the middle meningeal artery. As the artery bleeds, it pulls the dura away from the skull, creating a pouch that expands into the intracranial space.

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? a. Emergency surgery b. Diagnostic peritoneal lavage (DPL) c. Computed tomography scan d. Intraabdominal pressure monitoring

ANS: A Hemodynamically unstable patients with a positive Focused Assessment with Sonography for Trauma (FAST) scan generally undergo emergency surgery to achieve hemostasis. Diagnostic peritoneal lavage (DPL) is undertaken less frequently in many trauma centers. Computed tomography (CT) scanning is the mainstay of diagnostic evaluation in the hemodynamically stable patient with abdominal trauma; however, when the patient is hemodynamically unstable, the patient is taken to surgery. Intraabdominal pressure monitoring is done in the presence of intraabdominal hypertension.

What is the primary mechanism in the development of idiopathic thrombocytopenic purpura (ITP)? a. Destruction of platelets by lymphocytic antibodies b. Destruction of malignant cells through radiation or chemotherapy c. Formation of heparin antibodies d. Damage to the endothelium

ANS: A In idiopathic thrombocytopenic purpura (ITP), lymphocytes produce antibodies that begin to destroy existing platelets.

A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/s/cm-5

ANS: A Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock.

An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem? a. Sepsis b. Delirium c. Adult respiratory distress syndrome d. Acute kidney injury

ANS: A Increased heart rate, change in sensorium, increased temperature, and increased respiratory rate are all signs of sepsis in the presence of an existing infection.

A patient with a Le Fort III facial fracture has been admitted to the critical care unit. Which statements is true regarding this type of facial fracture? a. It is frequently associated with cerebrospinal fluid leaks. b. It is not as severe as Le Forte I and II injuries. c. The patient's airway is not usually compromised. d. It is associated with a low risk for hemorrhagic shock.

ANS: A Le Fort III fractures are associated with craniofacial disruption. Cerebrospinal fluid frequently leaks with Le Fort II and III fractures because there is frequently communication between the cranial base and the cribriform plate. Patients are at risk of airway occlusion from the tongue, hemorrhage, broken teeth, emesis, or bone fragments. Significant blood loss can occur with these injuries because of the extensive soft tissue and vascular damage that results.

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? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag

ANS: A Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest.

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

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

The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse understands that this disorder has which characteristic? a. Formation of thrombi b. Spontaneous epistaxis c. Elevated prothrombin times d. Massive peripheral ecchymoses

ANS: A Patients with immune-mediated heparin-induced thrombocytopenia (HIT) are at greater risk for thrombosis than bleeding. Vessel occlusion can result in the need for limb amputation, stroke, acute myocardial infarction, and even death. The resultant formation of fibrin platelet-rich thrombi is the primary characteristic of HIT that distinguishes it from other forms of thrombocytopenia and gives rise to its more descriptive name: white clot syndrome.

A patient has been admitted with 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? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility

ANS: A Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output.

During assessment of a new trauma patient, the nurse observes perianal ecchymosis. The nurse suspects the patient has what problem? a. Pelvic fracture b. Bladder trauma c. Rectal laceration d. Spleen laceration

ANS: A Signs of pelvic fracture include swelling, tenderness, and/or bruising to the pubis, iliac bones, hips, or sacrum. Perianal ecchymosis (scrotum or vulva), indicating extravasation of urine or blood, may be present.

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? a. Daily assessment for proper fit and effectiveness b. Removal of splints during showers and dressing changes c. Allowing for frequent breaks from splint use d. Passive and active range of motion may be used instead of splints

ANS: A Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked daily for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times, except to assess the graft site for pressure points during every shift. Splints to correct severe contracture may be off for 2 hours per shift to allow burn care and range-of-motion exercises.

The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? a. Zone of coagulation b. Peripheral zone c. Zone of stasis d. Zone of hyperemia

ANS: A The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the least. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.

A patient was thrown 30 feet from an open-top Jeep and straddled a row of mailboxes before landing on the ground. The patient has an open pelvic fracture. What characteristics of this injury are important for the nurse to understand? a. Aggressive fluid and blood replacement will probably be needed. b. The patient will probably be able to walk as soon as the patient is stable. c. The patient will probably not need surgery to stabilize her fracture. d. There is little likelihood of damage to the genitourinary or gastrointestinal tracts.

ANS: A The mortality rate for these injuries is high because, unlike closed pelvic fractures that bleed into the peritoneum, open pelvic fractures result in external exsanguinations.

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? a. Large doses of opioids given intramuscularly b. Intravenous opioids used in combination with oral antidepressants c. Large doses of opioids given subcutaneously d. Small doses of intravenous opioids titrated to effect

ANS: D Initially after burn injury, narcotics are administered intravenously in small doses and titrated to effect. The constant background pain may be addressed with the use of a patient-controlled analgesia device. When hemodynamic stability has occurred and gastrointestinal function has returned, oral narcotics can be useful. Intramuscular or subcutaneous injections must not be administered because absorption by these routes is unpredictable because of the fluid shifts that occur with burn injury.

A patient with multisystem trauma has been in the intensive care unit (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 blood pressure (BP), 92/66 mm Hg; heart rate (HR), 118 beats/min; temperature (T), 38.7° C; and central venous pressure (CVP), 5 mm Hg. What is the most likely cause of this hemodynamic picture? a. Septic shock b. Hemorrhagic shock c. Cardiogenic shock d. Neurogenic shock

ANS: A The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained.

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? a. Maintain adequate organ perfusion. b. Suppress antibody response that is destroying platelets. c. Treat life-threatening metabolic disturbances. d. Begin hypothermic therapy to prevent cerebral hemorrhage.

ANS: A The primary intervention in disseminated intravascular coagulation (DIC) is prevention. Being aware of the conditions that commonly contribute to the development of DIC and treating them vigorously and without delay provide the best defenses against this devastating condition. After DIC is identified, maintaining organ perfusion and slowing consumption of coagulation factors are paramount to achieving a favorable outcome.

Which of the following does NOT play a role in thrombin inhibition? a. Thromboxane A2 b. Antithrombin III c. Protein S d. Protein C

ANS: A The prostaglandin thromboxane A2 contributes to vasoconstriction and promotes further platelet degranulation. Excessive thrombin formation results in rapid consumption of coagulation factors and depletion of regulatory substances—protein C, protein S, and antithrombin.

A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. Decreased red blood cell production and fluid loss

ANS: A The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages.

Sickle cell anemia is the most prevalent in persons of which descent? a. West African b. Middle Eastern c. Pacific Islander d. Asian

ANS: A This genetic trait is primarily found in people of West African descent. The disease has also been linked to persons of sole European or Middle Eastern ancestry; however, this is extremely rare. The disease is not prevalent in persons of Asian or Pacific Islander descent.

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? a. Thoracotomy b. Pericardiocentesis c. Splenectomy d. Pneumonectomy

ANS: A Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/h for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures.

Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related to what physiologic change? a. Deterioration of cerebral and motor skills b. Poor vision and hearing c. Diminished pain perception d. Limited physiologic reserve

ANS: D Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of hypovolemia—tachycardia. Loss of physiologic reserve and the presence of preexisting medical conditions are likely to produce further conflicting hemodynamic data. An older patient's lack of physiologic reserve makes it imperative that early nutritional support is initiated.

A patient with severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize secondary brain injury? a. Hyperventilate the patient to keep PCO2 less than 30. b. Restrict fluids to keep central venous pressure less than 6 cm H2O. c. Maintain the patient's body temperature more than 37.5° C. d. Administer fluids to keep the systolic blood pressure greater than 90 mm Hg.

ANS: D Secondary injury can be caused by ischemia, hypercapnia, hypotension, cerebral edema, sustained hypertension, calcium toxicity, or metabolic derangements. Hypoxia or hypotension, the best-known culprits for secondary injury, typically are the result of extracranial trauma. Extreme vasodilation of the cerebral vasculature occurs in an attempt to supply oxygen to the cerebral tissue. This increase in blood volume increases intracranial volume and raises intracranial pressure.

A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply.) a. Blood cultures ×2 b. Wound cultures c. Urine cultures d. Sputum cultures e. Complete blood count (CBC) with differential

ANS: A, B, C, D A key measure in the treatment of septic shock is finding and eradicating the cause of the infection. At least two blood cultures plus urine, sputum, and wound cultures should be obtained to find the location of the infection before antibiotic therapy is initiated. Antibiotic therapy should be started within 1 hour of recognition of severe sepsis without delay for cultures.

The nurse is caring for a patient with blunt abdominal trauma. The nurse understands that patient is at risk for abdominal compartment syndrome. Which findings would the nurse expect to note as evidence of this complication? (Select all that apply.) a. Decreased cardiac output b. Increased peak pulmonary pressures c. Decreased urine output d. Hypoxemia e. Bradycardia

ANS: A, B, C, D Clinical manifestations of abdominal compartment syndrome include decreased cardiac output, decreased tidal volumes, increased peak pulmonary pressures, decreased urine output, and hypoxemia.

A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? (Select all that apply.) a. Dark tea-colored urine b. Decreased urine output c. Hypoxemia d. Diminished pulses e. Increased serum creatine kinase level

ANS: A, B, E Circulating myoglobin can lead to the development of kidney failure by three mechanisms: decreased renal perfusion, cast formation with tubular obstruction, and direct toxic effects of myoglobin in the kidney tubules. Dark tea-colored urine suggests myoglobinuria. The most rapid screening test is a serum creatine kinase level. Urine output and serial creatine kinase levels should be monitored. Hypoxemia and diminished pulses are not associated with rhabdomyolysis.

A patient has been admitted with immune thrombocytopenia purpura (ITP). Which sign and symptoms would the nurse expect to note to support this diagnosis? (Select all that apply.) a. Gingival bleeding b. Retinal hemorrhage c. Fluid retention d. Muscle cramps e. Petechial hemorrhages on legs

ANS: A, B, E Signs and symptoms of immune thrombocytopenia purpura (ITP) include the following. Integumentary:Petechial hemorrhage of lower extremities, ecchymoses, gingival bleeding, and spontaneous epistaxis. Neurologic: Sudden, severe headache; nausea and vomiting; seizures; focal neurologic deficits; and decreased level of consciousness. Renal: Hematuria. Gastrointestinal: Hematemesis, melena, and hematochezia. Other:Heavy menses in women and retinal hemorrhage. Laboratory: Decreased platelet count, often below 30,000 mm3.

Patients immobilized because of spinal trauma are at a high risk for contractures. The nursing management plan for these patients should include which preventive measures? (Select all that apply.) a. Consultation by physical therapist (PT) and occupational therapist (OT) early in the treatment of the patient. b. Turning and repositioning the patient every 2 hours as ordered by the physician. c. Range of motion exercises 1 month after the spine has been stabilized. d. Removal of splints every 4 hours and at bedtime. e. Hand splints for patients with paraplegia. f. Hand and foot splints for patients with quadriplegia.

ANS: A, B, F Physical therapy and occupational therapy personnel should be consulted early in the patient's course. Range-of-motion exercises are initiated as soon as the spine has been stabilized. Footdrop splints should be applied on admission to prevent contractures and prevent skin breakdown of the heels. Hand splints should be applied for patients with quadriplegia. Hand and foot splints should be removed every 2 hours.

The nurse is caring for a patient with extensive trauma to the lower extremities. The nurse understands that patient is at risk for compartment syndrome. Which findings would the nurse expect to note as evidence of this complication? (Select all that apply.) a. Paresthesia b. Decreased pulses c. Pain in the affected extremity d. Swelling in the affected extremity e. Decreased capillary refill

ANS: A, C, D Clinical manifestations of compartment syndrome include obvious swelling and tightness of an extremity, paresis, and pain of the affected extremity. Diminished pulses and decreased capillary refill do not reliably identify compartment syndrome because they may be intact until after irreversible changes have occurred. Elevated intracompartmental pressures confirm the diagnosis.

The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.) a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. b. Administer low-dose dopamine to maintain urine output greater than 30 mL/h. c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. e. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify patients who need hydrocortisone

ANS: A, C, D There is no evidence to support the use of low-dose dopamine to maintain urine output. An adrenocorticotropic hormone (ACTH) stimulation test should not be used to identify patients who need hydrocortisone.

The nurse is caring for a patient with heparin-induced thrombocytopenia (HIT). The nurse knows the patient is at high risk for bleeding and injury. Which interventions would be included in the plan of care? (Select all that apply.) a. Avoid intramuscular injections. b. Use a large-gauge intravenous cannula for venipunctures. c. Use a soft-bristled toothbrush when providing mouth care. d. Use a draw sheet when repositioning the patient in bed. e. Shave the patient with an electric shaver only.

ANS: A, C, D, E Bleeding precautions include all of these options except using a large-gauge intravenous cannula for venipunctures. If necessary, only small-gauge needles or cannulas should be used.

Major trauma patients are at high risk of developing deep venous thrombosis and pulmonary embolism. The nurse understands that trauma patients are at risk due to which factors? (Select all that apply.) a. Blood stasis b. Hypernatremia c. Injury to the intimal surface of the vessel d. Hyperosmolarity e. Hypercoagulopathy f. Immobility

ANS: A, C, E, F The factors that form the basis of venous thromboembolism (VTE) pathophysiology are blood stasis, injury to the intimal surface of the vessel, and hypercoagulopathy. Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and immobility. Hypernatremia and hyperosmolarity are associated with acute kidney injury.

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? a. Superficial, first-degree burn b. Partial-thickness, second-degree burn c. Deep dermal partial-thickness, second-degree burn d. Full-thickness, third-degree burn

ANS: B A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid, in turn, lifts off the thin damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth will heal in 7 to 21 days.

The nurse is caring for a patient who was admitted with 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? a. Administer fresh frozen plasma b. Obtain a serum lactate level c. Administer epinephrine d. Measure central venous pressure

ANS: B According to the Surviving Sepsis Campaign Bundles, the following interventions should be completed within 3 hours of time of presentation 1. Measure lactate level. 2. Obtain blood cultures prior to administration of antibiotics. 3. Administer broad spectrum antibiotics. 4. Administer 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L.

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? a. Infection b. Lack of blood supply c. Lack of lymphatic drainage d. Contamination

ANS: B After the pigskin is in place, it may be dressed with antibacterial-impregnated dressings or other forms of dressings. Pigskin usually is removed or dissolves because of a lack of blood supply in 5 to 7 days. The pigskin is packaged in a variety of ways and in various sizes. It can be treated with silver sulfadiazine and can be meshed or nonmeshed. Pigskin can be used for temporary coverage of full- and partial-thickness wounds, burn wounds, and donor sites.

What is the most common cause of disseminated intravascular coagulation (DIC)? a. Sepsis caused by gram-positive organisms b. Sepsis caused by gram-negative organisms c. Sickle cell anemia d. Burns

ANS: B Although all of these answers can cause disseminated intravascular coagulation (DIC), sepsis, particularly that caused by gram-negative organisms, can be identified as the culprit in as many as 20% of cases, making it the most common cause of DIC.

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? a. Sepsis b. Deep vein thrombosis c. Cardiac arrest d. Pneumonia

ANS: B Ascertaining a medical history that includes previous heparin therapy, deep vein thrombosis, or cardiovascular surgery that included the use of cardiopulmonary bypass can alert the nurse to potential problems.

A trauma patient's condition has deteriorated. The nurse notes changes in 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? a. Cardiac tamponade b. Hemothorax c. Open pneumothorax d. Ruptured diaphragm

ANS: B Assessment findings for patients with a hemothorax include hypovolemic shock. Breath sounds may be diminished or absent over the affected lung. With hemothorax, the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can be diagnosed on the basis of clinical manifestations of hypotension associated with the absence of breath sounds or dullness to percussion on one side of the chest.

A patient was admitted after a motor vehicle crash (MVC). The nurse knows that this type of injury is the greatest cause of what type of trauma? a. Spinal shock b. Blunt thoracic trauma c. Maxillofacial injuries d. Penetrating thoracic injuries

ANS: B Blunt trauma to the chest most often is caused by motor vehicle crashes (MVCs) or falls. Spinal shock is a condition that can occur shortly after traumatic injury to the spinal cord. Maxillofacial injury results from blunt or penetrating trauma. Blunt trauma may occur from motor vehicle, industrial, or athletic injuries; violent blows to the head; or falls. The penetrating object involved determines the damage sustained from penetrating thoracic trauma. Low-velocity weapons (eg, 22-caliber gun, knife) usually damage only what is in the weapon's direct path.

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. What other laboratory value would be valuable in definitively diagnosing the patient's condition? a. Fibrin split products b. D-Dimer level c. Bleeding time d. White blood cell count

ANS: B D-Dimers are exclusively indicative of clot degradation and assist in determining the degree of coagulopathy.

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? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume

ANS: B Disseminated intravascular coagulation (DIC) results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways.

A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital organs

ANS: B Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions.

The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS? a. Patient experiences hypometabolism. b. Patient experiences hypermetabolism. c. Patient experiences anorexia. d. Patient has gut dysfunction.

ANS: B Hypermetabolism in systemic inflammatory response syndrome (SIRS) or multiple-organ dysfunction syndrome (MODS) results in profound weight loss, cachexia, and loss of organ function. The goal of nutritional support is the preservation of organ structure and function. Although nutritional support may not definitely alter the course of organ dysfunction, it prevents generalized nutritional deficiencies and preserves gut integrity. Enteral nutrition may exert a physiologic effect that downregulates the systemic immune response and reduces oxidate stress.

Using the Parkland formula for fluid resuscitation and your 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. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL

ANS: B In a 75-kg person with a 37% burn injury (based on a rule of nines calculation: 18%—chest, 1%—perineum, 18%—right leg = 37% total body surface area [TBSA] burn), the Parkland formula estimates fluid resuscitation needs at 4 mL × 37 × 75 = 11,100 mL. In the first 8 hours after injury, half of the calculated amount of fluid is administered. This amount equals 5550 mL.

A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Nursing care for the patient includes which intervention? a. Keep the room cool, dark, and quiet. b. Maintain mean arterial pressure (MAP) at 85 to 95 mm Hg. c. Elevate the head of the bed 45 degrees. d. Resuscitate low blood pressure by only using intravenous fluid.

ANS: B Management of acute cervical spinal cord injury (SCI) involves close hemodynamic monitoring. Current guidelines for the management of acute cervical SCI cite that hypotension (systolic blood pressure less than 90 mm Hg) should be avoided or corrected as soon as possible after acute SCI. It is also considered an option to maintain the mean arterial pressure (MAP) at 85 to 90 mm Hg for the first 5 to 7 days after acute SCI to improve spinal cord perfusion. The room should be kept warm to avoid hypothermia. Elevating the head of the bed will often cause hypotension and is contraindicated until additional spinal cord injuries have been ruled out. Because of the profound vasodilation found with neurogenic shock, patients should be resuscitated with both intravenous fluids and vasopressors to restore intravascular volume as well as vascular tone.

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? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.

ANS: B Organ dysfunction may be the direct consequence of an initial insult (primary multiple-organ dysfunction syndrome [MODS]) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself.

What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure

ANS: B Preventing infection in burn patients is a true challenge and involves complex decision making. Considerable debate has been going on about the infection control precautions to use with burn patients. The burn wound is the most common source of infection in burn patients.

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? a. The size and depth of burn injury and the burning agent b. The age and present medical history of the patient c. The depth of the burn injury and the presence of soot in the sputum d. The medical history of the patient and the size and depth of the burn injury

ANS: D Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the above-mentioned factors, is of crucial importance in the overall plan of care and in decisions concerning patient management and appropriate referral to a burn center.

The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP). The nursing management plan for this patient would include which intervention? a. Instituting a heparin infusion of 1000 U/h b. Instructing the patient to blow his or her nose carefully c. Removing heparin from hemodynamic pressure monitoring systems d. Administering isotonic saline intravenously

ANS: B Recognizing potential hazards and providing a safe care environment is of utmost concern. For example, padding bed rails can protect the patient from bruising. Substituting sponge-tipped oral care devices for firm-bristled toothbrushes can help minimize mucosal trauma and bleeding, and the patient is instructed on how to blow his or her nose gently to avoid instigating epistaxis. When shaving patients, the use of an electric razor is preferred to reduce the risk of laceration associated with a blade. Venipuncture and intramuscular injections are avoided.

A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information? a. Shock is a physiologic state resulting in hypotension and tachycardia. b. Shock is an acute, widespread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in hypotension.

ANS: B Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple-organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? a. Distended neck veins b. Decreased level of consciousness c. Bounding radial and pedal pulses d. Widening pulse pressure

ANS: B Signs of hypovolemia include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure.

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? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. c. Start a norepinephrine drip to keep mean arterial blood pressure greater than 65 mm Hg. d. Administer crystalloid fluids.

ANS: B Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.

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. a. 28% b. 23.5% c. 45.5% d. 16%

ANS: B The arm represents 4.5%, the leg 18%, and the perineum 1%, totaling 23.5%.

How is the intrinsic coagulation pathway activated? a. Local blood vessels constrict at the injury site. b. Damaged subendothelium comes into contact with circulating blood. c. Tissue factor is released by injured vascular cells. d. Serotonin and histamine are released.

ANS: B The extrinsic pathway begins when vascular injury causes the release of tissue factor. The intrinsic pathway begins when damaged subendothelium comes into contact with circulating blood. The two pathways converge when fibrinogen and prothrombin are converted to their active forms and a clot is established.

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? a. Posterior cord syndrome b. Brown-Séquard syndrome c. Diffuse axonal injury d. Central cord syndrome

ANS: D Central cord syndrome is associated with cervical hyperextension/flexion injury and hematoma formation in the center of the cervical cord. This injury produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Posterior cord syndrome is associated with cervical hyperextension injury with damage to the posterior column. This results in the loss of position sense, pressure, and vibration below the level of injury. Brown-Séquard syndrome is associated with damage to only one side of the cord. This produces loss of voluntary motor movement on the same side as the injury, with loss of pain, temperature, and sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe prolonged posttraumatic coma that is not caused by a mass lesion, although DAI with mass lesions has been reported.

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? a. Uncontrolled pain b. Hypovolemia c. Worsening hypoxemia d. Decreased pulmonary compliance

ANS: D Circumferential full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Decreased compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes.

A patient has been admitted with tumor lysis syndrome (TLS). Which intervention would be incorporated into the plan of care to prevent the metabolic imbalances associated with this disorder? a. Give sodium polystyrene sulfonate for hypokalemia. b. Keep urine pH below 7.0. c. Restrict all oral fluids. d. Restrict foods containing potassium.

ANS: D Dietary restrictions of potassium and phosphorus may be necessary. The goals in treating hyperuricemia are to inhibit uric acid formation and to increase renal clearance. These can be accomplished through the administration of sodium bicarbonate to increase the pH of the urine to above 7.0, which increases the solubility of uric acid, preventing subsequent crystallization. Administration of intravenous fluids may be necessary early in the course of treatment if inadequate hydration exists. If potassium levels rise dangerously, Kayexalate (sodium polystyrene sulfonate) may be given orally, or if the patient is unable to tolerate oral medications because of nausea and vomiting, rectal instillation may be used.

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? a. Check circulatory status. b. Check electrolyte profile. c. Insert a urinary catheter. d. Obtain patient history.

ANS: D During the secondary survey, a head-to-toe approach is used to thoroughly examine each body region. The history is one of the most important aspects of the secondary survey. Additional interventions during the resuscitation phase involve placement of urinary and gastric catheters. During resuscitation from traumatic hemorrhagic shock, normalization of standard clinical parameters such as blood pressure, heart rate, and urine output are not adequate. Circulatory status is part of the primary survey.

A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine

ANS: D Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators.

Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria? a. Pure silver b. Bacitracin c. Mafenide acetate cream d. Silver sulfadiazine

ANS: D Silver sulfadiazine (SSD; Silvadene cream) is a broad-spectrum antimicrobial agent with bactericidal action against many gram-negative and -positive bacteria associated with burn wound infection. Mafenide acetate cream penetrates through burn eschar and is bacteriostatic against many gram-negative and -positive organisms. Its use is limited because the application is uncomfortable for the patient because it creates a burning sensation, and it is rapidly absorbed, requiring dressing changes two or three times daily. It is used routinely for coverage of small wounds. Bacitracin ointment is a topical agent applied to superficial burns and facial burns. Bacitracin is effective against gram-positive organisms but not against gram-negative organisms or fungal organisms. Silver has long been used for the treatment of wounds because of its broad-spectrum bacteriostatic properties. The wound moisture activates the silver and releases it into the wound. An advantage of silver dressings is that the dressing does not need to be changed daily because of the sustained release of silver. Silver dressings should be used judiciously and limited to 4 to 6 weeks despite the current absence of negative systemic or local consequences.

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? a. Used to assess respiratory status b. Used to assess circulatory status c. Used to assess pain status d. Used to assess level of consciousness

ANS: D The AVPU method can be used to quickly describe the patient's level of consciousness: A: alert, V: responds to verbal stimuli, P: responds to painful stimuli, and U: unresponsive.

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? a. Blanching of fingers and toes and loss of peripheral pulses b. Chest pain, pallor, and confusion c. Headache, impaired speech, and loss of motor function d. Dyspnea, pleuritic pain, and rales

ANS: D The presence of blanching and the loss of peripheral pulses, sensation, or motor function in a limb indicate peripheral vascular thrombi. Neurologic signs and symptoms such as confusion, headache, and impaired speech can signal the onset of cerebral artery occlusion and stroke. Acute myocardial infarction may be heralded by dyspnea, chest pain, pallor, and alterations in blood pressure. Thrombi in the pulmonary vasculature may be evidenced by pleuritic pain, rales, and dyspnea.

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? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% high-flow oxygen via a nonrebreathing mask.

ANS: D The treatment of choice for carbon monoxide (CO) poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation. The half-life of CO in the body is 4 hours at room air (21% oxygen), 2 hours at 40% oxygen, and 40 to 60 minutes at 100% oxygen.The half-life of CO is 30 minutes in a hyperbaric oxygen chamber at three times the atmospheric pressure. Currently, the use of hyperbaric oxygen is of controversial benefit in care of burn patients.

Which pathophysiologic event contributes to renal failure associated with tumor lysis syndrome? a. Hypocalcemia b. Elevated white blood cell count c. Metabolic acidosis d. Crystallization of uric acid in the renal tubules

ANS: D When therapy is initiated, tumor cell destruction releases nucleic acids, which are metabolized into uric acid. Metabolic acidosis ensues, resulting in crystallization of the uric acid in the distal tubules of the kidneys and leading to obstruction of urine flow. Glomerular filtration rates drop as the kidneys are unable to clear the increasing amounts of uric acid. Consequently, acute kidney injury eventually occurs.