nursing question and need support to help me learn.
When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the care provider?
Skin cool and clammy
Apical pulse 118 beats/min
Arterial oxygen saturation 91%
Calculate the mean arterial pressure (MAP) in mmHg for a patient with a blood pressure of 84/46mmHg. (Record answer to the nearest whole number)
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of pneumothorax in this client?
A low respiratory rate
Diminished breath sounds
The presence of a barrel chest
A sucking sound at the site of injury
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?
Slow deep respirations
Rapid deep respiration
Pain, especially with inspiration
A client with a chest injury has suffered a flail chest. The nurse assesses the client for which most distinctive sign of flail chest?
Paradoxical chest movement
Dyspnea, especially on exhalation
A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds and notes that the client has an absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?
Displaced endotracheal tube
Acute respiratory distress syndrome
A burn patient is brought into the emergency department with the following burns: half of the front torso, entire left arm, front of left leg. The nurse should record the TBSA burns as.
The client, who is one-day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first?
Assess the client pulse oximeter reading
Notify the rapid response team
Place the client in the Trendelenburg position
Check the client’s surgical dressing
The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which interventions should the nurse implement first?
Notify the respiratory therapist immediately
Ventilate with a manual resuscitation bag
Check the ventilator to resolve the problem
Auscultate the client’s lung sound
The client in the intensive care unit is on a ventilator. Which interventions should the nurse implement? (select all that apply)
Ensure there is manual resuscitation bag at the bedside
Monitor the client’s pulse oximeter reading every shift
Assess the client’s respiratory status every 2 hours
Check the ventilatory setting every 4 hours
Collaborate with the respiratory therapist
Which actions are essential for the nurse caring for a mechanically ventilated to prevent ventilator-acquired pneumonia (VAP) (Select all that apply)?
Keep the HOB elevated at least 30 degrees
Perform oral care every 12 hours
Suction every 1-2 hours around the clock
Turn and reposition the patient every 2 hours
Prevent pressure ulcers around the mouth
A patient in respiratory failure is diagnosed with a flail chest. After the patient is intubated, which treatment does the nurse expect to be implemented?
Positive end-expiratory pressure (PEEP)
Synchronized intermittent mechanical ventilator (SSIMV)
Bi-level positive airway pressure (Bi-PAP)
Peak inspiratory pressure (PIP)
An older adult patient arrives in the emergency department after falling off a roof. The nurse observes “sucking inward” of the loose chest during inspiration and a “puffing out” of the same area during expiration. Arterial blood gas (ABG) results show severe hypoxemia and hypercarbia. Which procedure does the nurse prepare for?
Chest tube insertion
A postoperative patient reports a sudden onset of shortness of breath and pleuritic chest pain. Assessment findings include diaphoresis, hypotension, crackles in the left lower lobe, and pulse oximetry of 85%. What does the nurse suspect has occurred with this patient?
A nurse is planning care for an adult client who sustained severe burn injuries. Which interventions should the nurse include in the plan of care? (select all that apply)
Limit visitors in the client’s room when immunosuppressed
Encourage raw foods to improve exposure to natural flora
Offer high-calorie, high protein foods or supplemental feeding
Ambulate two or three times a day and progress in length each time
Apply compression dressing before the graft heals to prevent scar formation
When assessing a patient who is severely bleeding and at risk for hypovolemic shock, the nurse anticipates which of the following?
Slow, labored breathing
Hot flushed skin
Weak, thready pulse
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burn 38 hours ago. Which finding should the nurse report to the provider?
Edema in the burned extremities
Severe pain at the burn sites
Urine output of 65ml/hr. over 2 hours
ABG pH 7.31, CO2 37, HCO3 31
When assessing a patient who has suffered a burn injury, the nurse classifies the burn as a deep partial-thickness burn based on the observation of which characteristics?
Painful, reddened skin
Charred skin with milky-white areas
Erythema and blisters
Erythema, pain, and swelling
The nurse is developing a care plan for a patient in the acute phase of a burn injury. Which of the following would be the priority nursing diagnosis for this patient?
Risk for falls r/t contracture of burned extremities
Risk for infection r/t slow healing graft donor site
Risk for denial r/t inability to participate in dressing change
Risk for ineffective coping r/t inability to look at burn wounds
A nurse in a burn treatment center is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client’s spouse asks the nurse what the procedure entails. Which nursing statement is appropriate?
Large surgical incisions will be made in the hardened dermal layer to improve circulation
This procedure involves placing the client into a shower and removing the dead tissue
A piece of healthy skin will be removed from an unburned area and grafted over the burned area
Surgical incisions will be made into the deep tissue, possibly to the bone, to permit better circulation
A nurse is caring for a client who has sustained burns over 37% of total body surface area. The client voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which?
Carbon monoxide poisoning
A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should:
Administer morphine sulfate IV push for the severe pain
Call the healthcare provider (HCP) to report the loss of the radial pulse
Continue to assess the arm every hour for any additional changes
Instruct the client to exercise the fingers and wrist
A patient who was admitted after receiving a blow to the head begins to show signs of shock. How should the patient be positioned?
With the head lower than the body
Flat with the legs elevated
Flat on the back
In a side-lying position
You receive an order for Dopamine 20 mcg/kg/minute. The bag is labeled Dopamine 100mg/50ml. The patient weighs 88 lbs. What is the infusion rate in ml/hr? Record answer to the nearest whole number.
Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful?
Hemoglobin is within normal limits
Urine output is 60 ml over the last hour
Pulmonary artery wedge pressure (PAWP)
Mean arterial pressure (MAP) is 65 mmHg
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
Avoid elevating head of bed
Check temperature every 2 hours
Monitor breath sounds frequently
Assess skin for flushing and itching
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm the diagnosis of neurogenic shock?
Cool, clammy skin
Apical heart rate 48 beats/min
Temperature 101.2 degrees F (38.4 degrees C)
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which statement indicates the nurse’s correct understanding of DIC?
DIC is controllable with lifelong heparin usage
DIC is a genetic disorder characterized by an elevated factor VIII count
DIC is a caused by abnormal coagulation involving fibrinogen
DIC is a genetic disorder involving vitamin K deficiency
During change of shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider?
Decreased bowel sounds
Apical pulse 110 beats/min
Pale, cool and dry extremities
New onset of confusion and agitation
A patient with septic shock has a urine output of 20 ml/hr for the past 3 hours. The pulse rate is 120, and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question?
Increased normal saline infusion
Prepare to give broad spectrum antibiotic
A client has been prescribed silver sulfadiazine for a burn injury. Which of the following findings would give the nurse reason to question the order for this topical burn cream?
WBC count of 10,000 per ml
The patient has a deep partial-thickness burn wound
The patient has a sulfa allergy listed on the chart
The patient has a full-thickness burn wound
A patient with shock of unknown etiology whose hemodynamic monitoring indicates a BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question?
Infuse normal saline at 250ml/hr
Keep head of bed elevated to 30 degrees
Give nitroprusside unless systolic BP is less than 90 mmHg
Administer dobutamine to keep systolic BP greater than 90 mmHg
Which assessment is important for the nurse to make to evaluate whether the treatment of a patient with anaphylactic shock has been effective?
A patient with neurogenic shock has just arrived in the emergency department after a driving accident. He has a cervical collar in place. Which of the following actions should the nurse take? (select all that apply)
Prepare to administer atropine IV
Obtained baseline body temperature
Prepare for intubation and mechanical ventilation
Administer large volumes of lactated Ringer’s solution
Assist the patient into a semi fowler’s position
When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock?
Placing the pulse oximeter on the ear for a patient with septic shock
Keeping the head of the bed flat for a patient with hypovolemic shock
Decreasing the room temperature to 68 degrees for a patient with neurogenic shock
Increasing the nitroprusside infusion rate for a patient with a high SVR
The patient with neurogenic shock is receiving a phenylephrine infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action?
The patient’s IV infusion site is cool and pale
The patient has warm dry skin on the extremities
The patient has an apical pulse rate of 58 beats/min
The patient’s urine output has never been 28 ml over the last hour
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
Avoid elevating head of bed
Check temperature every 2 hours
Monitor breath sounds frequently
Assess skin for flushing and itching
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse is which of the following?
Attach a cardiac monitor
Obtained the blood pressure
Check of the level of consciousness
Which information about a patient who is receiving vasopressin to treat septic shock is most important for the nurse to communicate to the health care provider?
The patient heart rate is 108 beats/min
The patient is complaining of chest pain
The patient’s peripheral pulses are weak
The patient’s urine output is 15 ml/hr
The nurse recognizes indication of respiratory distress include which of the following? (select all that apply)
The client who is two days postoperative following a pneumonectomy has an apical pulse (AP) rate of 128 beats per minute and a blood pressure (BP) of 80/50 mmHg which intervention should the nurse implement first?
Document and continue to monitor
Assess the client’s incisional wound
Prepare to administer dopamine, a vasopressor
Increase the client’s intravenous (IV) rate
A certified burn nurse is introducing a new nurse to the burn unit. The nurse is educating the new nurse on the degree staging of burns. Which of the following provides the correct description of wound to the correct level of injury?
Superficial thickness reddened skin, no blister presentation, heals quickly and completely
Superficial partial thickness; involves entire epidermis only
Full partial thickness: blisters typically form, deep normal injury, may need grafting
Full thickness: epidermal and dermal layer are destroyed, severe pain and edema
A client with a pulmonary embolism may have which of the following interventions? (Select all that apply.)
Inferior vena cava (IVC) filter
Chest tube placement
Heparin drug therapy
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse except?
Hemoglobin 10 g/dL
Sodium 143 mEq/L
Potassium 4.0 mEq/dL
A nurse is caring for a client who is receiving mechanical via an endotracheal tube. Which of the following actions should the nurse take?
Apply a vest restraint if self-extubation is attempted
Monitor daily ventilator settings
Document tube placement in centimeters at the angle of the jaw
Assess breath sounds every 2 hours
A client arrived at the burn unit more than two weeks ago. The care plan for this client requires assistance by the nurse to perform daily ROM exercises and help with mobility. The client tells the nurse he is no longer going to participate due to the pain it always causes. Which of the following should the nurse do next?
Call the doctor to report noncompliance with treatment
Remind the client that contractures hurt worse and to let you know when he is ready
Give him his ordered PRN dose of IV hydromorphone 4mgs with his scheduled PO oxycodone 10mgs 30 minutes prior to treatment to allow for pain free therapy.
Acknowledge the client’s concerns regarding pain, and discuss how to promote his exercise plan in a way to have less pain but also allow a therapeutic level of treatment
A client has been diagnosed with a pulmonary embolism. Which diagnostics and treatments does the nurse anticipate will be ordered? (Select all that apply.)
CT Angiogram (CTA)
A client in the intensive care unit (ICU) was recovering from moderate burns and smoke inhalation. His condition was improving, and plans were made to transfer him to a step-down unit. On the morning of the transfer, the client began to experience elevated temperatures and shortness of breath, urine output decreased to 10 mL/hr. Labs were drawn and indicated elevated WBCs. GFR creatinine and lever enzymes. This client is experiencing which disease process?
Acute respiratory failure (ARF)
Acute kidney injury (AKI)
Disseminated intravascular coagulation (DIC)
Multiple organ dysfunction syndrome (MODS).
After receiving report of four clients the nurse determines the order of care of the clients. Based on report, the nurse will prioritize the clients to see which one first?
Mottling of extremities in a newborn
Dry skin with tenting in a 72-year-old
Bradycardia in a 35-year-old athlete
Rapid shallow respirations in a healthy 18-year-old
A nurse is managing several IV medications to maintain the blood pressure of a client in hypovolemic shock. Which medication places the client at risk for a hypertensive reaction, requiring the nurse to assess the blood pressure at least every 15 minutes?
Sodium nitroprusside (Nipride)
A nurse is planning care for a client who has severe acute respiratory distress syndrome (ARDS). Which actions should the nurse include? (Select all that apply).
Conservative fluid therapy and diuretics
Administer antiviral and antibiotics for every cause of ARDS
Assess lungs hourly and suction to maintain airway
Maintain intubation and mechanical ventilator support
Consider dietician and enteral nutrition and/or parenteral nutrition
A nurse is caring for a client who has burn injuries to his trunk. The nurse explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching?
“I will be on a special shower table to enhance wound inspection and debridement.”
“The water temperature will be hot to improve blood flow and healing.”
“The nurse will use a wire-bristled brush to remove loose skin.”
“The nurse will use scissors to open small blasters.”
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which IV solution?
0.45% Sodium Chloride
Lactated Ringer’s solution
Dextrose 10% in water
0.9% sodium chloride
A nurse is educating a new nurse on the different types of shock. The new nurse is asked to identify which client is not experiencing distributive shock?
A client with septic-induced hypotension refractory to adequate fluid resuscitation
A client with extensive spinal cord injury at T4 and a heart rate of 40 beats per minute
A client with an extreme type of allergic reaction to penicillin and stridor
A client with a tension pneumothorax and cardiovascular compression.
A client who has an endotracheal tube is being considered for a tracheostomy. Which of the following criteria would support the placement of a tracheostomy in this client?
Client is unable to maintain airway when extubated
Client has been on the ventilator for 24 hours
Client has been diagnosed diabetes
Client is coughing and bucking the endotracheal tube.
A client is being treated for hypovolemic shock. As the nurse reassesses the client. Which finding indicates the interventions are effective?
Oxygen saturations remains unchanged
Core body temperature has increased to 99 degrees F
The client incorrectly states the month and year
Serum lactate and serum potassium levels are declining
Client presents with the following vital signs: B/P 90/60, temp 38.3C (101F), HR 116, RR 24. The client has a post-op abdominal incision that is warm and red. Which type of shock is this client in?
A nurse is assessing the provider in caring for a client who has developed a tension pneumothorax. Which actions should be performed first?
Assess the client’s pain
Large-bone needle thoracostomy
Prepare for chest tube insertion.
A client is being treated for distribute shock with IV vasopressin. The nurse expects the drug to have which effect on the client’s mean arterial pressure (MAP)?
Increased MAP with no change in vascular volume
Increased MAP by increasing vascular volume
Decreased MAP from widespread capillary leak
Decreased MAP from decreasing vascular volume
A client with 55% total body surface area burns (TBSA) arrives in the emergency department. The client weighs 160 pounds. Using the Parkland Burn Formula (Consensus formula), calculate the hourly flow rate (mL/hr) of Lactated Ringers during the first 8 hours of fluid resuscitation (mL/hr). (Round answer to the nearest whole number. Do not use a trailing zero.)
160lbs /2.2 =72.7272 kg
4 ML X 55 X 72.727272 =16000ml
16000/2 = 8000ml/8 hrs = 1000ml/hr
A nurse is caring for a client in shock. The nurse understands the client’s sympathetic nervous system (SNS) is still correctly attempting to compensate when the following is assessed? (SATA)
The client has decreased peripheral pulses
The client has an increasing thirst
The client has a decreased heart rate
The client has an increasing respiratory rate
The client has a widening pulse pressure
A nurse is caring for a client who is in the progressive stage of shock. Which finding should the nurse expect?
Blood pressures change from 129/78 (95) to 89/45 (60)
Blood pressures change from 95/55 (68) to 90/52 (65)
Blood pressures change from 100/50 (67) to 90/45 (60)
Blood pressure reading is undetectable
Which of the following interventions is not appropriate for a client diagnosed with a pneumothorax?
Apply wet to dry dressing on wound
Monitor respiratory and circulatory function
Assess for tracheal deviation
The nurse is caring for a client experiencing hypovolemic shock. Which of the following interventions would not be appropriate for this client? ***
Monitor intravenous fluid replacement.
Monitor vital signs
Monitor hemoglobin and hematocrit levels
Assist to a sitting position
A nurse is caring for a group of clients. Which client is at most risk for a pulmonary embolism?
A client who has a BMI of 24.
A postmenopausal active female
A long-distance truck driver
A client who consumes alcohol
A nurse is assessing a client who has fluid volume overload from cardiogenic shock. Which manifestation of cardiogenic shock should the nurse expect?
Heart Rate 121bpm
Blood pressure 165/91 mm/Hg
Respiratory Rate 12 bpm
Temperature 103.1 F
A nurse is assessing the fluid status of a client being treated for a burn during the emergent phase. Which of following is an indicator of adequate fluid resuscitation?
Blood pressure 90/60 mmHg
Pulse 115 bpm
Urine output at least 30 mL/hr
The pathophysiology of acute respiratory distress syndrome is characterized by which of the following?
Increased lung compliance
Increased surfactant production
A nurse is caring for a client with arterial blood gas (ABG) results pH 7.21 pCO2 60, paO2 42 HCO3 22. Which medication should the nurse prepare to administer first?
The nurse is caring for a client who suffered a third-degree burn to his hands after a house fire. He presented with an airway injury secondary to smoke inhalation and has been intubated. The client is currently on the ventilator with 100% FIO2. Based on this information, which of the following would be a sign or symptom of acute respiratory distress syndrome (ARDS)?
Respiratory rate 14
ABG results show PaO2 50
Fatigue and weakness
Urine output 580 mL last shift
A client is receiving warfarin after pulmonary embolism (PE). The nurse evaluates the lab results and notifies the physician that the client’s Coumadin level is therapeutic when which of the following numbers is reported?
International normalized ratio (INR) 2.8
Partial thromboplastin time (PTT) 24 seconds
International normalized ratio (INR) 1.1
Prothrombin time (PT) 14 seconds
A nurse is reviewing the health records of clients. Which client is at least risk for developing acute respiratory distress syndrome (ARDS)?
A client who experienced a near-drowning incident in freshwater
A client following coronary artery bypass graft surgery
A client who has a hemoglobin of 10.1 mg/dL post 1-unit PRBC
A client who is experiencing acute pancreatitis and vomiting
A client presented to the ED after receiving second and third degree burns from a kitchen grease spill. The tops of both thighs, the groin area, and lower abdomen were the areas of injury. About three hours after the injury, the client begins to decompensate and is being prepped for intubation. Regarding the change in the client's status, which explanation by the nurse is correct when educating the client's family?
Even a burn as little as 25% of the body can cause a systemic response, requiring emergency management"
The client is complaining of serve pain and will be intubated to safety given pain medication and seductive
The client is experiencing a paralytic ileum and requires intubation to prevent further damage
Fluid shift in the body immediately cause an increased cardiac output and increased tissue profusion which can negatively affect the healing process
A nurse is caring for a client who is in the non-progressive (compensatory) stage of hypervolemic shock. Which finding should the nurse anticipate? ***
Multi-organ Dysfunction Syndrome and seizures
Increase thirst reflex and moderate vasoconstriction
pH 7.5 and potassium level of 3.0 mEq/L
Decrease in MAP by 20 points from baseline
A nurse is reviewing the health records of clients. Which client is at greatest risk for developing Acute Respiratory Distress Syndrome (ARDS) and Multiple Organ Dysfunction Syndrome (MODS)?
A client who experienced neurogenic shock
A client following anaphylactic shock
A client who is experiencing septic shock
A client who is experiencing obstructive shock
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