MD4

Question 1

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum

Answer 1

ANS: B
The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient’s fluid intake but not as urgently as the hypotension

Question 2

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?

a. Serum hematocrit of 42%
b. Serum sodium level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours

Answer 2

ANS: B
Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention

Question 3

`A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

a. Skin turgor
b. Daily weight
c. Urine output
d. Edema presence

Answer 3

ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

Question 4

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?

a. “Drink more fluids in the late evening.”
b. “Increase fluids if your mouth feels dry.”
c. “More fluids are needed if you feel thirsty.”
d. “If you feel confused, you need more to drink.”

Answer 4

ANS: B
An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.

Question 5

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?

a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.

Answer 5

ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.

Question 6

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?

a. “I will try to drink at least 8 glasses of water every day.”
b. “I will use a salt substitute to decrease my sodium intake.”
c. “I will increase my intake of potassium-containing foods.”
d. “I will drink apple juice instead of orange juice for breakfast.

Answer 6

ANS: D
Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

Question 7

A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?

a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurse’s station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves..

Answer 7

ANS: B
The patient should be placed near the nurse’s station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.

Question 8

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?

a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 10 mEq/hour.
c. Only give the KCl through a central venous line.
d. Discontinue cardiac monitoring during the infusion

Answer 8

ANS: B
IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysthymias

Question 9

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

a. Infuse 5% dextrose in water at 125 mL/hr.
b. Administer 3% saline at 50 mL/hr for a total of 200 mL.
c. Administer IV morphine sulfate 4 mg every 2 hours PRN.
d. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.

Answer 9

ANS: A
Because the patient’s gastric suction has been depleting electrolytes, the IV solution should include electrolyte replac ement. Solutions such as lactated Ringer’s solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

Question 10

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

Answer 10

ANS: D
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3-

Question 11

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

a. Give the prescribed PRN lorazepam (Ativan).
b. Encourage the patient to take deep slow breaths.
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Administer the prescribed normal saline bolus and insulin.

Answer 11

ANS: D
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis

Question 12

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?

a. Pallor
b. Edema
c. Confusion
d. Restlessness

Answer 12

ANS: B
The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

Question 13

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema

Answer 13

ANS: A
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

Question 14

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?

a. Hematocrit 28%
b. Absence of skin tenting
c. Decreased peripheral edema
d. Blood pressure 110/72 mm Hg

Answer 14

ANS: C
Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient’s protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

Question 15

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

Answer 15

ANS: A

The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses

Question 16

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?

a. Digoxin (Lanoxin) 0.25 mg/day
b. Metoprolol (Lopressor) 12.5 mg/day
c. Ibuprofen (Motrin) 400 mg every 6 hours
d. Lantus insulin 24 U subcutaneously every evening

Answer 16

ANS: A
Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

Question 17

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

a. Maintain the patient on bed rest.
b. Auscultate lung sounds every 4 hours.
c. Monitor for Trousseau’s and Chvostek’s signs.
d. Encourage fluid intake up to 4000 mL every day.

Answer 17

ANS: D
To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau’s and Chvostek’s signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.

Question 18

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?

a. Skim milk
b. Grape juice
c. Mixed green salad
d. Fried chicken breast.

Answer 18

ANS: A
Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in phosphate and are not restricted.

Question 19

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?

a. Daily alcohol intake
b. Dietary protein intake
c. Multivitamin/mineral use
d. Over-the-counter (OTC) laxative use

Answer 19

ANS: A
Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels

Question 20

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?

a. “The prescribed infusion can be given more rapidly when the patient has a central
line.”
b. “The hypertonic solution will be more rapidly diluted when given through a
central line.”
c. “There is a decreased risk for infection when 25% dextrose is infused through a
central line.”
d. “The required blood glucose monitoring is based on samples obtained from a
central line.”

Answer 20

ANS: B
The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

Question 21

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

a. Avoid using friction when cleaning around the CVAD insertion site.
b. Use the push-pause method to flush the CVAD after giving medications.
c. Obtain an order from the health care provider to change CVAD dressing.
d. Position the patient’s face toward the CVAD during injection cap changes.

Answer 21

ANS: B
The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. A provider’s order is not necessary. The patient should turn away from the CVAD during cap changes.

Question 22

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

a. K+ 3.4 mEq/L (3.4 mmol/L)
b. Ca+2 7.8 mg/dL (1.95 mmol/L)
c. Na+ 154 mEq/L (154 mmol/L)
d. PO4-3 4.8 mg/dL (1.55 mmol/L)

Answer 22

ANS: C
The elevated serum sodium level is consistent with the patient’s neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium, phosphate, and calcium levels vary slightly from normal but do not require immediate action by the nurse.

Question 23

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

a. Oral temperature of 100.1°F
b. Serum sodium level of 138 mEq/L (138 mmol/L)
c. Gradually decreasing level of consciousness (LOC)
d. Weight gain of 2 pounds (1 kg) over the admission weight

Answer 23

ANS: C
The patient’s history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported but do not indicate a need for rapid action to avoid complications.

Question 24

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

a. Skin turgor
b. Heart sounds
c. Mental status
d. Capillary refill

Answer 24

ANS: C
Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

Question 25

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?

a. Notify the patient’s health care provider.
b. Obtain an order to draw a potassium level.
c. Review the last magnesium level on the patient’s chart.
d. Teach the patient about magnesium-containing antacids.

Answer 25

ANS: A
The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with hyperkalemia.

Question 26

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

a. Check to make sure the nasogastric tube is patent.
b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the ABG results.
d. Teach the patient how to take slow, deep breaths when anxious.

Answer 26

ANS: B
The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain. Checking the nasogastric tube can wait until the patient has been medicated for pain.

Question 27

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?

a. Flush a saline lock with normal saline.
b. Verify blood products prior to administration.
c. Remove the patient’s central venous catheter.
d. Titrate the flow rate of vasoactive IV medications.

Answer 27

ANS: A
A LPN/LVN has the education, experience, and scope of practice to flush a saline lock with normal saline. Administration of blood products, adjustment of vasoactive infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice

Question 28

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient’s bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips.

Answer 28

ANS: A
Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospam

Question 29

Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete?

a. Presence of the Chvostek’s sign
b. Abnormal serum potassium level
c. Decreased thyroid hormone level
d. Bleeding on the patient’s dressing

Answer 29

ANS: A
The patient’s symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding

Question 30

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

a. Arterial blood pH is 7.32.
b. Serum calcium is 18 mg/dL.
c. Serum potassium is 5.1 mEq/L.
d. Arterial oxygen saturation is 91%

Answer 30

ANS: B
The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.

Question 31

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

a. The bibasilar breath sounds are decreased.
b. The patellar and triceps reflexes are absent.
c. The patient has been sleeping most of the day.
d. The patient reports feeling “sick to my stomach.”

Answer 31

ANS: B
The loss of the deep tendon reflexes indicates that the patient’s magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

Question 32

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

a. The patient’s radial pulse is 105 beats/min.
b. There are crackles throughout both lung fields.
c. There is sediment and blood in the patient’s urine.
d. The blood pressure increases from 120/80 to 142/94 mm Hg

Answer 32

ANS: B
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli

Question 33

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?

a. Monitor ionized calcium level.
b. Give oral calcium citrate tablets.
c. Check parathyroid hormone level.
d. Administer vitamin D supplements

Answer 33

ANS: A
This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.

Question 34

A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?

a. Obtain the baseline weight.
b. Check the patient’s blood pressure.
c. Draw blood for serum electrolyte levels.
d. Ask about extremity numbness or tingling .

Answer 34

ANS: B
Because the patient’s history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient’s perfusion status

Question 35

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

a. Notify the health care provider.
b. Offer reassurance to the patient.
c. Auscultate the patient’s breath sounds.
d. Give prescribed PRN morphine sulfate IV

Answer 35

ANS: C
The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.

Question 36

After receiving change-of-shift report, which patient should the nurse assess first?

a. Patient with serum potassium level of 5.0 mEq/L who is complaining of
abdominal cramping
b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking
for a glass of water
c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and
hyperactive deep tendon reflexes
d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue
calcium-phosphate precipitates

Answer 36

ANS: C
The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening complications

Question 37

During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?

a. Deficient fluid volume
b. Impaired gas exchange
c. Risk for injury: Seizures
d. Risk for impaired skin integrity

Answer 37

ANS: C
The patient’s muscle cramps and low serum calcium level indicate that the patient is at risk for seizures, tetany, or both. The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.

Question 38

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?

a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction

Answer 38

ANS: B
With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

Question 39

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse’s priority?

a. Monitoring urine output every 4 hours.
b. Continuing to monitor the laboratory results.
c. Increasing the rate of the ordered IV solution.
d. Typing and crossmatching for a blood transfusion.

Answer 39

ANS: C
The patient’s laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient’s fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every1 hour).

Question 40

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient’s respiratory rate.
d. Reposition the patient in high-Fowler’s position and reassess breath sounds.

Answer 40

ANS: B
The patient’s history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

Question 41

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?

a. 219 mL/hr
b. 625 mL/hr
c. 938 mL/hr
d. 1875 mL/hr

Answer 41

ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr

Question 42

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes
d. Measure hourly urine output.

Answer 42

ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient’s weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

Question 43

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?

a. Administer vitamins and minerals intravenously.
b. Insert a feeding tube and initiate enteral feedings.
c. Infuse total parenteral nutrition via a central catheter.
d. Encourage an oral intake of at least 5000 kcal per day.

Answer 43

ANS: B
Enteral feedings can usually be started during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient’s caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients unless the gastrointestinal tract is not available for use.

Question 44

While the patient’s full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination?

a. Use sterile gloves when removing dressings.
b. Wear gown, cap, mask, and gloves during care.
c. Keep the room temperature at 70° F (20° C) at all times.
d. Give IV antibiotics to prevent bacterial colonization of wounds.

Answer 44

ANS: B
Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

Question 45

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?

a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the fingers.
c. Assist the patient to a supine position with a small pillow under the head.
d. Position the patient in a side-lying position with rolled towel under the neck.

Answer 45

ANS: B
The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow or rolled towel because the head should be maintained in an extended position in order to avoid contractures.

Question 46

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first?

a. Monitor the pulses every hour.
b. Notify the health care provider.
c. Elevate both legs above heart level with pillows.
d. Encourage the patient to flex and extend the toes.

Answer 46

ANS: B
The decrease in pulse and numbness in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient’s circulation.

Question 47

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?

a. Bowel sounds
b. Stool frequency
c. Stool occult blood
d. Abdominal distention

Answer 47

ANS: C
H2 blockers and proton pump inhibitors are given to prevent Curling’s ulcer in the patient who has sustained burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite.

Question 48

Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns?

a. ketorolac c. gabapentin (Neurontin)
b. lorazepam (Ativan)
c. gabapentin ( Neurontin)
d. hydromorphone (Dilaudid)

Answer 48

ANS: D
Opioid pain medications are the best choice for pain control. The other drugs are used as adjuvants to enhance the effects of opioids.

Question 49

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving?

a. “I’m glad the scars are only temporary.”
b. “I will avoid using a pillow, so my neck will be OK.”
c. “Do you think dark beige makeup will cover this scar?”
d. “I don’t think my boyfriend will want to look at me now.”

Answer 49

ANS: C
The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

Question 50

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function?

a. Monitor white blood cells (WBCs).
b. Continue to measure the urine output.
c. Assess that blisters and edema have subsided.
d. Encourage the patient to eat an adequate number of calories.

Answer 50

ANS: B
The patient’s urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. WBCs may increase or decrease, based on the patient’s immune status and any infectious processes. The WBC count does not indicate kidney function. Although adequate nutrition is important for healing, it does not ensure adequate kidney functioning.

Question 51

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient?

a. Bananas
b. Orange gelatin
c. Vanilla milkshake
d. Whole grain bagel

Answer 51

ANS: C
A patient with a burn injury needs high-protein and high-calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice but low in protein. Bananas are a good source of potassium but are not high in protein and calories.

Question 52

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

a. Oral temperature
b. Peripheral pulses
c. Extremity movement
d. Pupil reaction to light

Answer 52

ANS: C
All patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.

Question 53

An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first?

a. Remove nonadherent clothing and wristwatch.
b. Apply an alkaline solution to the affected area.
c. Place a cool compress on the area of exposure.
d. Cover the affected area with dry, sterile dressings.

Answer 53

ANS: A
With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if the face was exposed). Flush the chemical from the wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

Question 54

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?

a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check oxygen saturation.

Answer 54

ANS: D
Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.

Question 55

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

a. Auscultate the patient’s lung sounds.
b. Determine the extent and depth of the burns.
c. Give the prescribed hydromorphone (Dilaudid).
d. Infuse the prescribed lactated Ringer’s solution.

Answer 55

ANS: A
A patient with facial and chest burns is at risk for inhalation injury and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured

Question 56

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

a. Assess pain level.
b. Place on heart monitor.
c. Check potassium level
d. Assess oral temperature.

Answer 56

ANS: B
After an electrical burn, the patient is at risk for life-threatening dysrhythmias and should be placed on a heart monitor. Assessing the oral temperature and pain is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important, but it will take time before the laboratory results are back. The first intervention is to place the patient on a heart monitor and assess for dysrhythmias so that they can be monitored and treated if necessary.

Question 57

Eight hours after a thermal burn covering 50% of a patient’s total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider?

a. Blood pressure is 95/48 per arterial line.
b. Urine output of 41 mL over past 2 hours.
c. Serous exudate is leaking from the burns.
d. Heart monitor shows sinus tachycardia of 108.

Answer 57

ANS: B
The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 mm Hg systolic and the pulse rate should be less than 120 beats/min. Serous exudate from the burns is expected during the emergent phase.

Question 58

Which patient should the nurse assess first?

a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain
b. A patient with smoke inhalation who has wheezes and altered mental status
c. A patient with full-thickness leg burns who is scheduled for a dressing change
d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr

Answer 58

ANS: B
This patient has evidence of lower airway injury and hypoxemia, and should be assessed immediately to determine the need for O2 or intubation (or both). The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications

Question 59

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit?

a. A patient who has twice-daily burn debridements to partial-thickness facial burns
b. A patient who has just returned from having a cultured epithelial autograft to the
chest
c. A patient who has a weight loss of 15% from admission and will have enteral
feedings started
d. A patient who has blebs under an autograft on the thigh and has an order for bleb
aspiration

Answer 59

ANS: C
An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

Question 60

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient’s skin color is bright red. Which action should the nurse take first?

a. Insert two large-bore IV lines.
b. Check the patient’s orientation.
c. Assess for singed nasal hair and dark oral mucous membranes.
d. Place the patient on 100% O2using a nonrebreather mask.

Answer 60

ANS: D
The patient’s history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting O2 at 100%. The other actions can be taken after the action to correct gas exchange.

Question 61

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?

a. Hematocrit of 53%
b. Serum sodium of 147 mEq/L
C. Serum potassium of 6.1 mEq/L
d. Blood urea nitrogen of 37 mg/dL

Answer 61

ANS: C
Hyperkalemia can lead to life-threatening dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.

Question 62

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse?

a. The new nurse uses clean gloves when applying antibacterial cream to a burn
wound.
b. The new nurse obtains burn cultures when the patient has a temperature of 95.2°
F (35.1° C).
c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a
dressing change.
d. The new nurse calls the health care provider when a nondiabetic patient’s serum
glucose is elevated.

Answer 62

ANS: A
Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.

Question 63

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

a. Inspect the contact burns.
b. Check the blood pressure.
c. Stabilize the cervical spine.
d. Assess alertness and orientation.

Answer 63

ANS: C
Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

Question 64

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?

a. Keep the right arm in a position of comfort.
b. Avoid the use of sustained-release narcotics.
c. Teach about the purpose of tetanus immunization.
d. Apply water-based cream to burned areas frequently

Answer 64

ANS: D
Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury.

Question 65

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, “I’m sorry that I’m still alive. My life will never be normal again.” Which response by the nurse is best?

a. “Most people recover after a burn and feel satisfied with their lives.”
b. “It’s true that your life may be different. What concerns you the most?”
c. “Why do you feel that way? It will get better as your recovery progresses.”
d. “It is really too early to know how much your life will be changed by the burn.”

Answer 65

ANS: B
This response acknowledges the patient’s feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate but do not acknowledge the anxiety and depression that the patient is expressing.

Question 66

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer’s solution that the nurse will give during the first 8 hours?

Answer 66

ANS: 600 mL

Question 67

. The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient’s total body surface area (TBSA) has been injured?

Answer 67

ANS: 27%

Question 68

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient’s chest? (Put a comma and a space between each answer choice [A, B, C, D, E].)

a. Apply sterile gauze dressing.
b. Document wound appearance.
c. Apply silver sulfadiazine cream.
d. Give IV fentanyl (Sublimaze).
e. Clean wound with saline-soaked gauze.

Answer 68

ANS:
D, E, C, A, B
Because partial-thickness burns are very painful, the nurse’s first action should be to give pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.

Question 69

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question?

a. Administer furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Give hydrocortisone (Solu-Cortef) 100 mg IV.
d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg.

Answer 69

ANS: A
Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock require large amounts of fluid replacement. If the patient remains hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation

Question 70

. A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question?

a. Elevate head of bed to 30 degrees.
b. Infuse normal saline at 250 mL/hr.
c. Hold nitroprusside if systolic BP is less than 90 mm Hg.
d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

Answer 70

ANS: B
The patient’s elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP.

Question 71

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?

a. Inspiratory crackles c. Cool, clammy extremities
b. Heart rate 45 beats/min
c. Cool, clammy extremities
d. Temperature 101.2°F (38.4°C)

Answer 71

ANS: B
Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Question 72

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?

a. Increase the rate for the dopamine infusion.
b. Decrease the rate for the nitroglycerin infusion.
c. Increase the rate for the sodium nitroprusside infusion.
d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

Answer 72

ANS: C
Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

Question 73

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for

a. furosemide .
b. nitroglycerin .
c. norepinephrine.
d. sodium nitroprusside .

Answer 73

ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

Question 74

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?

a. Auscultate bowel sounds.
b. Ask the patient about nausea.
c. Check stools for occult
d. Palpate for abdominal tenderness.

Answer 74

ANS: C
Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration

Question 75

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication?

a. 5% albumin infusion
b. furosemide (Lasix) IV
c. Epinephrine (Adrenalin) drip
d. hydrocortisone (Solu-Corte

Answer 75

ANS: B
The PAWP indicates that the patient’s preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock

Question 76

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient’s arrival, the nurse will obtain

a. a dopamine infusion.
b. a hypothermia blanket.
c. Lactated ringers solution
d. two 16-gauge IV catheter

Answer 76

ANS: D
A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer’s solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

Question 77

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?

a. Hemoglobin is within normal limits.
b. Urine output is 65 mL over the past hour.
c. Central venous pressure (CVP) is normal.
d. Mean arterial pressure (MAP) is 72 mm Hg

Answer 77

ANS: B
Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion

Question 78

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?

a. Check temperature every 2 hours.
b. Monitor breath sounds frequently.
c. Maintain patient in supine position.
d. Assess skin for flushing and itching

Answer 78

ANS: B
Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

Question 79

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

a. The patient is receiving low dose dopamine.
b. The patient’s central venous pressure is 3 mm Hg.
c. The patient is in sinus tachycardia at 120 beats/min.
d. The patient has had no urine output since being admitted.

Answer 79

ANS: B
Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient’s low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

Question 80

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?

a. No new heart murmurs
b. Decreased troponin level
c. Warm, pink, and dry skin
d. Blood pressure of 92/40 mm Hg

Answer 80

ANS: C
Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock

Question 81

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective?

a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation

Answer 81

ANS: D
Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

Question 82

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?

a. The patient’s serum creatinine level is elevated.
b. The patient complains of intermittent chest pressure.
c. The patient’s extremities are cool and pulses are weak.
d. The patient has bilateral crackles throughout lung fields.

Answer 82

ANS: A
The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient’s diagnosis of cardiogenic shock

Question 83

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

a. Give normal saline IV at 500 mL/hr.
b. Give acetaminophen (Tylenol) 650 mg rectally.
c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg

Answer 83

ANS: A
Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

Question 84

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education?

a. Placing the pulse oximeter on the ear for a patient with septic shock
b. Keeping the head of the bed flat for a patient with hypovolemic shock
c. Maintaining a cool room temperature for a patient with neurogenic shock
d. Increasing the nitroprusside infusion rate for a patient with a very high SVR

Answer 84

ANS: C
Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

Question 85

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?

a. Skin cool and clammy
b. Heart rate of 118 beats/min
c. Blood pressure of 92/56 mmHg
d. O2 saturation of 93% on room air

Answer 85

ANS: A
Because patients in the early stage of septic shock have warm and dry skin, the patient’s cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient’s status.

Question 86

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to

a. obtain the blood pressure.
b. check the level of orientation.
c. administer supplemental oxygen.
d. obtain a 12-lead electrocardiogram.

Answer 86

ANS: C
The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2.

Question 87

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?

a. New onset of confusion
b. Decreased bowel sounds
c. Heart rate 112 beats/min
d. Pale, cool, and dry extremities

Answer 87

ANS: A
The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

Question 88

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first?

a. Insert two large-bore IV catheters.
b. Provide O2 at 100% per non-rebreather mask.
c. Draw blood to type and crossmatch for transfusions.
d. Initiate continuous electrocardiogram (ECG) monitoring

Answer 88

ANS: B
The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented.

Question 89

A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?

a. The patient’s heart rate is 58 beats/min.
b. The patient’s extremities are warm and dry.
c. The patient’s IV infusion site is cool and pale.
d. The patient’s urine output is 28 mL over the past hour.

Answer 89

ANS: C
The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate actioN

Question 90

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first?

a. Give epinephrine.
b. Administer diphenhydramine.
c. Start continuous ECG monitoring.
d. Draw blood for complete blood count (CBC)

Answer 90

ANS: A
Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed

Question 91

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider?

a. The patient’s urine output is 18 mL/hr.
b. The patient is complaining of chest pain.
c. The patient’s peripheral pulses are weak.
d. The patient’s heart rate is 110 beats/minute.

Answer 91

ANS: B
Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient’s diagnosis, and should be reported to the health care provider but does not indicate an immediate need for a change in therapy.

Question 92

After change-of-shift report in the progressive care unit, who should the nurse care for first?

a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in
the lung bases
b. Patient with suspected urosepsis who has new orders for urine and blood cultures
and antibiotics
c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate
of 54 beats/minute
d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and
a blood pressure of 108/58 mm Hg

Answer 92

ANS: B
Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.

Question 93

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provideR?

a. Temperature and IV site appearance
b. Oxygen saturation and breath sounds
c. Platelet count and presence of petechiae
d. Blood pressure, pulse rate, respiratory rate.

Answer 93

ANS: C
The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will also be discussed with the health care provider but does not indicate that the patient’s condition is deteriorating or that a change in therapy is needed immediately

Question 94

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)?

a. Prepare to administer atropine IV.
b. Obtain baseline body temperature.
c. Infuse large volumes of lactated Ringer’s solution.
d. Provide high-flow O2 (100%) by nonrebreather mask.
e. Prepare for emergent intubation and mechanical ventilation

Answer 94

ANS: A, B, D, E
All of the actions are appropriate except to give large volumes of lactated Ringer’s solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer’s solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate

Question 95

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)?

a. Ambulate postoperative patients as soon as possible after surgery.
b. Use aseptic technique when manipulating invasive lines or devices.
c. Remove indwelling urinary catheters as soon as possible after surgery.
d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
e. Advocate for parenteral nutrition for patients who cannot take in adequate
calories

Answer 95

ANS: A, B, C, D
Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS

Question 96

A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on the infusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many milliliters per hour?

Answer 96

ANS: 27

Question 97

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].)

a. Give vancomycin 1 g IV.
b. Obtain blood and urine cultures
c. Start norepinephrine 0.5 mcg/min.
d. Infuse normal saline 2000 mL over 30 minutes.
e. Titrate oxygen administration to keep O2 saturation above 95%.

Answer 97

ANS:
E, D, C, B, A
The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics.