Burns and trauma
1) An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which a... [Show More] ction should the nurse take first?
Ans: Apply oxygen and continuous pulse oximetry
2) Nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks why am I taking this medication How should the nurse respond.
Ans: it helps prevent stomach ulcers, which are common after burns.
3) Nurse reviews laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately?
Ans: serum potassium 6.5 mEq/L
4) Nurse cares for a client who has burn injuries. Client wife asks when will his high risk for infection decrease? How should nurse respond?
Ans: When all of his burn wounds have closed.
5) Nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which lab value should nurse monitor while client is prescribed this therapy?
6) Nurse cares for client with burn injuries. Which intervention should nurse implement to reduce clients pain?
Ans: administer prescribed intravenous morphine sulfate
7) Mr Blackburn experienced burns to anterior torso and bilateral upper extremities on anterior and posterior portions. HR 110 bpm (other vital signs I can’t remember). Mrblackburn is taken to a:
Ans: level one trauma center
8) RN is calculating IV fluid replacement for MrBlackBurn with the following information:
Ans: The teacher threw this question out for us because this question was the second question before having the backstory (number 7) so I am not sure what the actual answer is.
9) Nurse assess client admitted with deep-partial thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
Ans: urine output of 20 mL/hr
10) A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)?
Ans: lower blood volume lowers MAP
11) A nurse is caring for a male client after surgery. Clients respiratory rate has increased from 12 to 18 breaths/min and pulse increased from 86 to 98 bpm since last assessed. Complains of “feeling dizzy”. What action by nurse is best?
Ans: assess clients prefusion
12) A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. Spouse asks why client needs insulin if client is not diabetic. What response by nurse is best?
Ans: high glucose is common in shock and needs to be treated
13) Client is receiving norepinephrine (Lovophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?
Ans: alert and oriented, answering questions
14) A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider?
Ans: elevated lactate level of 6 (anything over 4 is elevated)
15) Mr. Wright is admitted to ICU. He is restless. Respirations become shallow at 30/min. SPO2 is 88% on nonrebreather mask of 10L/min FiO2. Stat ABGs show acidosis and decreased PaO2. Heart rate is 130/min, pulse is thread, Hgb and HCT are low, capillary refill is greater than 3 seconds with widespread vasoconstriction. MAP is 50 mmHG (his normal is 63). Foley shows 15 mL urine per hour. Pt is intubated and central lines placed. Mr. Wright is experiencing the shock syndrome:
Ans: non-progressive stage
16) A student nurse is preparing morning meds for a client who had a stroke. The student plans to hold docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best?
Ans: Give the Colace anyways. Do not skip. Stoke patients need constant bowel stimulation.
17) A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?
Ans: when did problems start. When did symptoms first begin.
18) A stroke patient has ataxia. What is important to include in nursing care plan.
Ans: use a gait belt
19) The RN is implementing the resuscitation bundle for Mr. Carter who has progressed to severe sepsis. Within six hours of the initial septic shock manifestations, the RN
Ans: all of the above (A, B & C) the answers should include checking lactate acid frequently, keeping MAP above 65, and treating with vasopressors if fluid replacement doesn’t work
20) Mr. Wright 28 years, arrives in emergency department after multiple vehicle accident. Right femur is fractured, BP 92/66, HR 110 bpm, RR 24, spo2 93% nasal cannula. 0.9% is infusing into left antecubital fossa. Trauma RN’s immediate concern for mr wright is:
Ans: hypovolemic shock
21) Client’s mean arterial pressure is 50 mmHg and intracranial pressure is 15 mmHG. Based on clients cerebral perfusion pressure what should the nurse anticipate for client?
Ans: poor prognosis and mental condition
22) Mrs. Twitch’s BP is 90/50 mmHg supine. What is first priority for fluid balance?
Ans: Increase blood volume and preload with 0.9% Normal saline
23) Client recovering from lumbar puncture. Which complication should alert nurse to ugently contact health care provider?
Ans: nausea and vomiting
24) Client is in emergency department and having a stroke and needs a carotid artery angioplasty with stenting. The client’s mental status is deteriorating. What action by the nurse is most appropriate:
Ans: Quickly try to find family to sign consent form
25) A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a sever headache and has vomited. What action by the nurse takes priority?
Ans: Call rapid response team and notify provider [Show Less]