1. The nurse should interpret the arterial blood gas results shown below as which of the following? pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
... [Show More] mEq/L
a. respiratory alkalosis
b. metabolic acidosis
c. metabolic alkalosis
d. respiratory acidosis
Feedback: The ABGs shown indicate the pH is high which would mean alkalosis. The PaCO2 is low which is the opposite of the pH and indicates that the respiratory system is the primary problem. The HCO3 is within normal levels. Remember the acronym ROME when interpreting ABGs.Lewis 2017, pgs 290-291abcK
2. The nurse is caring for a client who is receiving prescribed intravenous (IV) fluids at 50 ml/hr, has voided 300 ml in 24-hours and reports having a headache. The nurse notes the client's laboratory results show a low urine specific gravity level. Which of the following actions should the nurse take?
a. Encourage the client to increase their fluid intake.
b. Decrease the intravenous fluids.
c. Administer prescribed antibiotics.
d. Assist the client to ambulate to increase their metabolic rate.
Feedback: Acute renal failure manifests as oliguria, anuria, or normal urine volume. Oliguria (less than 400 mL/d of urine) is the most common clinical situation seen in acute renal failure along with a low urine specific gravity; anuria (less than 50 mL/d of urine) and normal urine output are not as common. In acute renal failure you want to encourage the client to increase their fluid intake to prevent dehydration. Administering antibiotics will not increase the client's decreased urine output. Decreasing IV fluids will be putting the client at risk for dehydration. Increasing the metabolic rate will not assist the client in their urine output deficit. Lewis 2017, pgs. 1071-1072abkd
3. The plan of care for a client with a low potassium level includes providing information about the effects of medications and the dietary intake of foods high in potassium. Which of the following information should the nurse use to evaluate if the outcome for the plan was met?
a. laboratory data
b. physical assessment
c. health history
d. client statements
Feedback: The interventions are aimed at increasing the potassium level of the client, and achievement would be measured by evaluating laboratory data. Potassium levels cannot be measured by physical assessment, health history information, or client statements. Lewis 2017, pgs. 282-283
4. The nurse caring for a client experiencing acute hypoxemic respiratory failure due to V/Q mismatch is evaluating the client’s plan of care. Which of the following interventions would be appropriate for the client’s care plan?
a. Initiate 24% to 32% oxygen via face mask.
b. Provide high flow supplemental oxygen via nasal cannula.
c. Provide oxygen via noninvasive positive pressure ventilation (NIPPV).
d. Initiate invasive positive pressure ventilation (PPV) via endotracheal tube for SaO2 below 90%.
Feedback: The nurse should understand that acute hypoxemic respiratory failure due to V/Q mismatch requires low levels of oxygen either via nasal cannula or using a face mask at 24% to 32% oxygen. This helps improve the PaO2 and SaO2 levels. Without knowing the client’s baseline SaO2 an intervention to initiate PPV vie ET tube for SaO2 would be inappropriate. NIPPV is typically the treatment of choice for hypoxemia secondary to an intrapulmonary shunt, not V/Q mismatch.Lewis 2017, pgs. 1615-1616
5. The nurse is caring for a client with right sided pneumonia (PN) and helps position the client in the left Sims position. The nurse should evaluate the client’s response to the position by doing which of the following?
a. Compare the client’s PaO2 level with the previous level.
b. Assessing the client’s pain level.
c. Ask the client to perform coughing and deep breathing.
d. Compare the client’s pH and HCO3 levels with the baseline levels.
Feedback: Clients with unilateral lung disease should be positioned with the healthy lung in a dependent position. This helps to mobilize the secretions which makes it easier to expectorate. The client’s PaO2 level compared to the previous level would give the nurse a good indication if the client’s ventilation has increased. Lewis 2017, pgs. 1610-1611k, 1624-1625k, acd by omission
6. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is mechanically ventilated with positive end-expiratory pressure (PEEP). Which of the following should alert the nurse that the client is having complications from PEEP? Select all that apply.
a. tachycardia
b. hypopnea
c. decreased urine output
d. diminished lung sounds
e. hypertension
Feedback: PEEP is indicated in clients with ARDS. PEEP provides positive pressure at the end of expiration to keep the alveoli open. This positive pressure can increase the intrathoracic pressure. When intrathoracic pressure increases, the client will have a decrease in preload, which can decrease cardiac output. When there is a decrease in cardiac output, the client can have tachycardia, hypotension, and decreased perfusion to the kidneys. With increased intrathoracic pressure, barotrauma or pneumothorax can occur. A client on mechanical ventilation should have equal and bilateral breath sounds, diminished breath sounds may indicate a pneumothorax.Lewis 2017, pg. 1577Kbe
7. The nurse received report from the previous shift for a client who was intubated for acute respiratory failure (ARF) less than one hour ago. Which of the following test results would be a priority for the nurse to follow-up?
a. end-tidal CO2 (ETCO2)
b. complete blood count (CBC)
c. electrocardiogram (ECG)
d. mixed venous O2 saturation (SvO2)
Feedback: After a client is intubated the ETCO2 should be evaluated because this confirms proper tube placement within the airway immediately after intubation. A CBC, ECG and SvO2 are also done after intubation but would not be a priority over correct tube placement.Lewis 2017, p. 1614
A client with chronic obstructive pulmonary disease (COPD) arrives in the emergency department (ED) reporting shortness of breath and dyspnea on minimal exertion. Which of the following findings would be a priority for the nurse to report to the health care provider?
Answers
:
Response Feedback:
SaO2 level is 91%
bibasilar lung crackles
the client is sitting in the tripod position
the client’s respirations have decreased to 10 breaths/min
The client is going into acute respiratory failure if the respirations have dropped to 10 breaths/min. Crackles, tripod position and SaO2 of 91% are all common findings for a client with COPD. Lewis 2017, pgs. 1613-1614abck
• Question 2 0 out of
2.5 points
The nurse caring for a client scheduled for surgery administers prescribed intravenous (IV) midazolam hydrochloride and the client then demonstrates signs of an overdose. The nurse should collaborate with the surgical team to do which of the following actions next?
Answers: administer prescribed epinephrine prepare to defibrillate the client
ventilate the client with an oxygenated bag-valve mask
titrate prescribed intravenous flumazenil
Response Feedback:
The nurse should have a bag-valve mask in the client’s room because midazolam hydrochloride can lead to respiratory acidosis if it is administered too quickly. The client does not need to be shocked back into a normal rhythm or to receive epinephrine unless cardiac compromise developed after the respiratory arrest. The client would receive titrated dosing of flumazenil to reverse the midazolam, but first the nurse should ventilate the client. Lewis 2017, pgs. 288stem, 1610stem, 1614-1615k, bcd by omission
• Question 3 2.5 out of
2.5 points
The nurse has attended a staff education conference about fluid balance. Which of the following statements, if made by the nurse, would indicate a correct understanding of homeostatic mechanisms in the body that regulate body fluid? Select all that apply.
Answers "Clients with increased levels of aldosterone are at risk for fluid loss."
:
"The amount of fluid loss through exhalation has no impact on fluid balance."
"I will monitor urine output to measure the kidney's effect on fluid volume balance."
"Clients who have a lack of antidiuretic hormone (ADH) are at risk for fluid volume deficit (FVD)." "Thirst triggers a mechanism in the hypothalamus to maintain fluid balance."
Response Feedback:
The adrenals act to regulate fluid balance with the use of aldosterone. Decreased blood volume promotes increased aldosterone which results in sodium and water retention. Approximately 300 ml of water is lost daily through exhalation (insensible water loss). Low levels of antidiuretic hormone (ADH) have an impact on fluid balance. The thirst center in the hypothalamus regulates oral intake by sensing intracellular dehydration. The kidneys regulate extracellular fluid (ECF) volume by selective retention and excretion of body fluids. Lewis 2017, pgs. 274-275kde
• Question 4 0 out of
2.5 points
The nurse should interpret the arterial blood gas results shown below as which of the following? pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L
Answers: respiratory acidosis
metabolic alkalosis respiratory alkalosis metabolic acidosis
Response Feedback:
The ABGs shown indicate the pH is low which would mean acidosis. The PaCO2 is within normal levels and the HCO3 is low indicating a metabolic disturbance. Remember the acronym ROME when interpreting ABGs. Lewis 2017, pgs. 290-291kbcd
• Question 5 0 out of
2.5 points
The nurse is reviewing the arterial blood gas (ABG) results for a client who was admitted with a bowel obstruction and has nasogastric tube (NG) with continuous suction. Which of the following ABGs would indicate to the nurse the client is experiencing a complication from the NG tube?
Answers: pH = 7.50 PaCO2 = 40 HCO3 = 39
pH = 7.28 PaCO2 = 41 HCO3 = 19
pH = 7.30 PaCO2 = 50 HCO3 =25
pH = 7.47 PaCO2 = 30 HCO3 = 22
Response Feedback:
Clients who have a prescription for continuous suction are at increased risk for metabolic alkalosis indicated by pH =7.50 CO2 = 40 HCO3 = 39, due to a loss of hydrogen and chloride ions from gastric fluids. Gastric fluids are acidic.
• Question 6 0 out of
2.5 points
The nurse is caring for a client who is receiving prescribed intravenous (IV) fluids at 50 ml/hr, has voided 300 ml in 24-hours and reports having a headache. The nurse notes the client's laboratory results show a low urine specific gravity level. Which of the following actions should the nurse take?
Answers: Administer prescribed antibiotics. Decrease the intravenous fluids.
Assist the client to ambulate to increase their metabolic rate.
Encourage the client to increase their fluid intake.
Response Feedback:
Acute renal failure manifests as oliguria, anuria, or normal urine volume. Oliguria (less than 400 mL/d of urine) is the most common clinical situation seen in acute renal failure along with a low urine specific gravity; anuria (less than 50 mL/d of urine) and normal urine output are not as common. In acute renal failure you want to encourage the client to increase their fluid intake to prevent dehydration. Administering antibiotics will not increase the client's decreased urine output. Decreasing IV fluids will be putting the client at risk for dehydration. Increasing the metabolic rate will not assist the client in their urine output deficit. Lewis 2017, pgs. 1071-1072abkd
• Question 7 0 out of
2.5 points
The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which of the following actions by the nurse would help prevent ventilator associated pneumonia (VAP)?
Answers: maintaining the head of the client's bed elevated at least 10 degrees suctioning of the client's oral cavity secretions every shift practicing meticulous hand hygiene
ensuring the respiratory therapist changes the ventilator circuit tubing every 4 hours
Response Feedback:
Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. The client will need oral suctioning more frequently than every shift and at least 30-degree head of the bed elevation. It is not necessary to change the ventilator circuit tubing every 4 hours. The more frequently the circuit is broken, the greater the risk for pathogen entry. Lewis 2017, p. 1623kbcd
• Question 8 0 out of
2.5 points
The nurse in the emergency department (ED) is caring for a client who reports acute dyspnea, pain and anxiety. The client’s blood pressure is 140/85 mm/Hg, pulse is 110 beats/minute and SaO2 is 85%. ABG values are; pH 7.50, PaCO2 29 mm/Hg, and HCO3 24 mm/Hg. Which of the following actions should the nurse take? Select all that apply.
Answers: encourage the client to breathe slowly
obtain a medical history from the client to determine the cause of symptoms
administer oxygen therapy
administer prescribed pain medication
prepare the client for intravenous therapy to promote compensation
Response Feedback:
The client is experiencing respiratory alkalosis based on the ABG levels. The pH is high and the PaCO2 is low. The nurse should administer oxygen, and pain medication and encourage the client to slow the breathing because pain can cause respiratory alkalosis and hyperventilation increases the pH levels. Obtaining as much of a medical history from the client as possible is key to treating the cause. With respiratory alkalosis, compensation is typically not possible because the client requires aggressive treatment of the hypoxemia.
Lewis 2017 pgs. 288-289ck, stem, 1614-1615k
1. Patient on PEEP (believe) experiencing ARDS (select all that apply)
a. Beta blocker b. Loop diuretic
c. Bronchodilator
d. Something else corticosterian
Look it up
1. The nurse assists the provider with a liver biopsy at the bedside. Which position does the nurse put the patient in after the biopsy?
Supine with head elevated on one pillow Semi-fowlers with two pillows under the leg
Right side lying with a folded towel under the puncture site
Left side lying with a small pillow under the puncture site
2. A patient is hospitalized for severe anorexia, fatigue, mild jaundice, hepatomegaly, and abnormal liver function tests. The physician suspects viral hepatitis. In planning care, which patient outcome does the nurse assign the highest priority?
Maintains adequate nutrition Maintains usual exercise regimen Adapts to changes in appearance
Definitely identifies source of exposure to hepatitis virus
3. Select all the potential causes for hepatic inflammation (double check this answer)
Virus
Penicillin Acetaminophen Alcohol Chocolate
4. A patient admitted to the hospital with a diagnosis of cirrhosis has a massive ascites’s and difficulty breathing. The nurse performers which intervention as a priority measure to assist the patient with breathing?
Reposition side to side every 2 hours Auscultate the lung sounds every 4hours Encourage deep breathing exercises Elevate the head of the bed 60 degrees
5. A home health nurse visits a patient who was recently diagnosed with cirrhosis and provides home care management instructions to the patient. Which statement by the patient indicates the need for further instructions?
I will obtain adequate rest
I should monitor my weight regularly
I should include sufficient carbs in my diet
I will take acetaminophen (Tylenol) if I get a headache
6. The nurse administers lactulose to a patient with cirrhosis the patient complains of diarrhea. The nurse explains that it is important to take the drug for which effect?
Prevention of constipation Promotion of fluid loss
Reduction in serum ammonia levels
Prevention of gastrointestinal bleeding
7. A patient with liver cancer has severe ascites and shortness of breath. The physician plans a paracentesis. The nurse prepares the patient for the paracentesis with which action?
Have client empty bladder
Position patient flat on right side
Have them lie flat with a small pillow under the small of his back Sedate the client with versed
8. The patient is admitted to the ED with vomiting of bright red blood. Which info is most important for the nurse to obtain during assessment?
Vital signs and symptoms of hypovolemia
History of prior bleeding Medication client is taking Current medical problems
21. (WORDED DIFFERENTLY ON TEST): A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for?
A) Maintaining positive chest-wall pressure
B) Monitoring pleural fluid osmolarity
C) Providing positive intrathoracic pressure
D) Removing excess air and fluid
22. (WORDED DIFFERENTLY ON TEST): A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
A) To remove air from the pleural space
B) To drain copious sputum secretions
C) To monitor bleeding around the lungs
D) To assist with mechanical ventilation
23. While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude?
The system is functioning normally. The patient has a pneumothorax.
The system has an air leak.
The chest tube is obstructed.
25. The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what?
A) Diminished or absent breath sounds on the affected side
B) Paradoxical chest wall movement with respirations
C) Sudden loss of consciousness
D) Muffled heart sounds
27. The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?
70 Years old man who aspirated before
A resident with mid-stage Alzheimers disease
A 92-year-old resident who needs extensive help with ADLs A resident with severe and deforming rheumatoid arthritis
30. The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
A) Attach the condom prior to erection.
B) A condom may be reused with the same partner if ejaculation has not occurred.
C) Use skin lotion as a lubricant if alternatives are unavailable.
D) Hold the condom by the cuff upon withdrawal.
1. The nurse has provided dietary education to a client with gallbladder disease. The nurse should reinforce teaching if the client chose which of the following food choices for a meal?
a. The patient should avoid fried foods such as fried chicken, as fatty foods may bring on an episode of cholecystitis.
2. The nurse provided teaching for a client who is scheduled to have a laparoscopic cholecystectomy. Which of the following statements by the client would indicate a correct understanding of the teaching?
a. The client having a laparoscopic cholecystectomy can shower 24 to 48 hours after the procedure and is usually discharged if there are no complications the same day or day after the procedure.
3. The nurse has taught a client with diabetes mellitus, type 1 (DM-1) about exercise and glucose control. Which of the following actions by the client would indicate the need for further teaching?
a. When the client is ketonic, exercise may result in an increase in blood glucose level.
4. The nurse is caring for a client who fell at home and is diagnosed with a right hip fracture. Which of the following would be most important for the nurse to assess? a. Because impaired circulation can cause permanent damage, neurovascular
assessment of the affected leg is always a priority assessment.
5. The nurse is assessing an assigned client with a left fractured femur for complications. Which of the following findings would require immediate action by the nurse?
a. Fat emboli may occur with fractures of the long bones and pelvis which can be fatal.
6. The nurse in the ED is caring for a client who has a closed lower extremity fracture that has just been realigned and splinted by the physician. Which of the following actions should the nurse take first?
a. Palpating for a dorsalis pedis pulse is an appropriate way to assess arterial circulation in a fractured lower extremity.
7. The nurse is preparing an conference about agents of terrorism. Which of the following information should the nurse include in the conference? Select all that apply.
a. Explosive devices can include TNT, dynamite and cause blast, crush or penetrating injuries.
b. Nerve agent poisoning can be treated with atropine and pralidoxime chloride.
c. Radioactive dispersal devices (RDDs) include a mix of explosives and radioactive material like pellets.
8. The nurse working in the ED is caring for a female client who has a spiral fracture to the right arm and ecchymosis to the right eye. The clients spouse states the client fell at home and the nurse notes the client has multiple ED visits in the last 6 months for other injuries. Which of the following actions would be most appropriate for the nurse to take? Select all that apply.
a. The nurse should report the findings to the charge nurse who will then call the appropriate agencies to investigate the suspected abuse.
b. The nurse should also attempt to interview the client alone so the client feels safe answering questions honestly.
c. The nurse can additionally provide information to the client about legal rights and a safe house or escape plan.
9. The nurse is participating in a mass causality drill. Which of the following clients should the nurse see first?
a. (Abd pain, weak thready pulse, and cap refill of 3-4 sec) The client is showing signs of decreased perfusion but is treatable and if not treated immediately they could have life-threatening complications.
10. A nurse is providing triage at a disaster site of a workplace explosion. A 40-year-old client is burned over 65% of the body; the burns are second and third-degree burns, but the client is conscious. The nurse should tag the client with which of the following triage colors?
a. The client would be triaged blue due to the unlikelihood of survival.
1. A patient presents with liver injury due to history of Tylenol abuse. On arrival the patient is unconscious. After giving him 3 liters of IV fluids the nurse does an assessment. The findings were bilateral 2+ pedal edema, BP 160/90, HR 115. What would be the priority assessment the nurse should do next?
a. Assess the lung sounds.
2. After interventions, stopping fluids, and giving a small dose of Lasix the patient became a little responsive. ABG lab results come back and are as follows: pH 7.28 PaCo2 38 PaO2 89 HCO3 17. Is there a sign of acid base imbalance?
a. Yes, metabolic acidosis.
3. A COPD patient is admitted with hypoxemia due to VQ mismatch. The nurse is anticipating the delivery system that is used to provide oxygen. What type of oxygen flow would you provide for this client?
a. Low levels of oxygen either via nasal cannula or using a face mask at 24%-32% oxygen.
4. A trauma patient who has acute heart failure has not gotten out of bed and has not been using the incentive spirometer has become very restless. Vital signs reveal signs of decreased cardiac output (low BP, bradycardic, and a thready pulse). A chest x ray reveals pneumonia. What would be the priority intervention for this patient?
a. Prepare them for intubation.
5. What medication prescribed for the patient above would you want to clarify? a. Azithromycin due to the client’s heart condition.
6. The patient is found to have fluids in the lungs due to bronchiectasis (damage to the airways making it difficult to clear mucus) and requires postural drainage 3x daily. What would be some essential teaching for this patient regarding postural drainage?
a. It needs to occur prior to or 3 hours after meals, use of pillows to position client, give bronchodilator (albuterol) before the procedure, percuss over a towel to ensure there is no discomfort.
7. A patient presents to the ED with complaints of feeling fluttering of the heart. The MD orders for this patient to be placed on telemetry. Looking at the strip, how would you calculate the HR?
a. Count the QRS complexes and multiply by 10 (for a 6 sec strip).
1. The nurse, on the mental health unit, is caring for a client who has had several verbal outbursts, is pacing around the unit and is at risk for assaultive behavior. Which of the following statements by the nurse would be most appropriate?
a. "Please take a time-out in your room."
2. The nurse is planning care for a client with moderate rheumatoid arthritis (RA). Which of the following nonpharmacologic interventions should the nurse include in the client's plan of care? Select all that apply.
a. Applying splints to rest inflamed joints,
b. Using Velcro fasteners on clothes to aid in dressing,
c. Applying moist heat to joints to relax muscles and relieve pain.
3. The nurse is planning care for a client who is newly diagnosed with human immunodeficiency virus (HIV). Which of the following prescribed prophylactic measures should the nurse include in the client's plan of care? Select all that apply.
a. Hep B b. Influenza
c. pneumococcal vaccines
4. The nurse is planning care for a client who has a recent diagnosis of multiple sclerosis (MS). Which of the following interventions should the nurse include in the client's care plan?
a. Encouraged to increase the fiber in his or her diet, void 30 minutes after drinking to help train the bladder and avoid constipation, and participate in daily muscle stretching to help alleviate and relax muscle spasms
5. The nurse is changing the descending colostomy for a client with a history of Crohn's disease. Which of the following findings should be a priority for the nurse to follow up?
a. A colostomy stoma should be bright, beefy red and moist. A dark purple-blue dry stoma may indicate compromised circulation or ischemia and a pale stoma can indicate anemia.
6. While performing a genital assessment on a 26-year-old male client, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. Which of the following should the nurse suspect the client is experiencing?
a. genital warts
7. The nurse is caring for a client who fell at home and is diagnosed with right hip fracture. Which of the following would be most important for the nurse to assess?
a. neurovascular assessment of the affected leg is always a priority assessment
8. The nurse is planning care for a client in the emergency department (ED) with an open fracture of the radius. The nurse should include which of the following interventions as a priority in the client's plan of care?
a. "Risk for infection"
1. What should you not give to someone in cardiogenic shock? (intervention)
2. If someone has diabetes insipidus and shock at the same time, what would you anticipate doing for them?
a. (foley to monitor urine output and make sure they have 2 large bore IV sites to give fluids)
3. What would you give to someone if they had a severe reaction to CT contrast dye? (medication) (**possibly Epi, antihistimines?)
4. If someone developed shock after getting an antibiotic for cellulitis, what would you give them? (medication)
5. Know about neurogenic shock
6. Sometimes shock can manifest as anxiety
7. Interventions you might take if someone went from SIRS to MODS
8. What might be an intervention you would do for someone who is in MODS who is also in a coma?
a. (test blood in aspirated fluid in NG tube to see if it is from stomach ulcers)
9. Someone who is badly burned on neck and torso from gas grill?
***(Wrap pt. in a clean bedsheet while you are waiting for the ambulance) (Possibly question below)
The nurse plans care for a male patient who suffered thermal burns to the entire posterior aspect of his body when he fell on an outdoor grill. Which patient need is likely to be the problem of this patient in the emergent phase?
a. Maintain tissue oxygenation
b. Halt progression of the burn
c. Maintain intravascular volume
d. Prevent invasion of pathogens
10. What is something that occurs early on with a major burn?
A patient is brought to the emergency department with a burn injury. The nurse knows that the first systematic event after a major burn injury is what?
a. Hemodynamic instability
b. Gastrointestinal hypermotility
c. Respiratory arrest
d. Hypokalemia
11. What is a priority finding of a patient that was in a house fire?
**(Singed nose hairs) (Possibly question below)
A patient is admitted to the emergency department with first and second degree burns after being involved in a house fire. Which of the following assessment findings would alert you to the presence of an inhalation injury? (SATA)
a. Singed nasal hair
b. Generalized pallor
c. Painful swallowing
d. Burns on the upper extremities
e. History of being involved in a large fire
12. Always medicate before doing a burn dressing
**Possibly
The nurse is reviewing the medication record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before wound debridement?
a. Ketorolac (Toradol)
b. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d. Hydromorphone (Dilaudid) [Show Less]