NSG 4100/ NSG4100 Exam 4 V2– Latest 2026/2027 Update – Advanced Medical- Surgical Nursing | Questions and Verified Answers | 100 out of 100

NSG 4100/ NSG 4100 Exam 4 V2– Latest 2026/2027 Update – Advanced Medical- Surgical Nursing | Questions and Verified Answers | 100 out of 100 2026 / 2027 Academic Year Q: The pt w fibromyalgia is suffering from pain at 12 of the 18 identification sites, including the neck & upper back & knees. The pt also reports non-refreshing sleep, depression, & being anxious when dealing w multiple tasks. The nurse should teach this pt about what treatments? Select all that apply: a. Minimal aerobic exercise b. Relaxation strategy (biofeedback) c. Anti-seizure during phenytoin d. Serotonin reuptake inhibitor (e.g. sertraline) e. Establish a regular sleep pattern B, D, E Q: The nurse caring for a client w a head injury would recognize which assessment finding as early signs of increased ICP? Select all that apply: a. Kussmaul breathing b. Projectile vomiting c. Weakness in one extremity d. Headache not aggravated by movement of straining e. Decreased urine output f. Papilledema A, C, D Q: A nurse caring for a client diagnosed to have head injury. Which of the following situations needs intervention by the nurse? a. The padded side rails up b. The bed is adjusted to low level c. The client's spouse turns on the TV one hour in the afternoon and 3 hours in the evening d. The head of bed is elevated at 30 degree angle C Q: The critical care nurse is caring for a client w a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimulus and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? a. The client has purposeful movement when the nurse rubs the sternum b. The client extends the upper and lower extremities in response to painful stimuli c. The client is aimlessly thrashing in the bed when a noxious stimuli is applied B Q: The nurse is caring for clients in the ED. Which client should the nurse assess first? a. The client w an epidural hematoma b. The client who had a seizure who is in the postictal state c. The client diagnosed w R/O encephalitis who has a headache d. The client w multiple sclerosis who has scanning speech A Q: A female pt has experienced an episode of myasthenic crisis. The nurse would assess whether the pt has precipitating factors such as: a. Getting too little exercise b. Taking excess medication c. Omitting doses of medication d. Intake of fatty foods C Q: A pt is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this pt's care, the nurse would expect to administer what priority medication? a. Hydrochlorothiazide (HydroDIURIL) b. Furosemide (Lasix) c. Mannitol (Osmitrol) d. Spriolactone (Aldactone) C Q: The nurse is caring for a pt who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume r/t fluid restriction & osmotic diuretic use. What would be an appropriate intervention for this diagnosis? a. change the pt's position as indicated b. monitor serum electrolytes c. maintain NPO status d. monitor arterial blood gas (ABG) values B Q: A pt who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the pt's plan of care? a. monitoring of pulse oximetry b. administration of a low-protein diet c. administration of thorough oral hygiene d. fluid restriction as ordered C Q: A nurse is admitting a pt w a severe migraine headache and a hx of acute coronary syndrome. What migraine medication would the nurse question for this pt? a. Rizatriptan (Mazalt) b. naratriptan (Amerge) c. sumatriptan succinate (Imitrex) d. zomitriptan (Zomig) C Q: The nurse is caring for a pt w increased ICP. The pt has a nursing dx of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis? a. copes w sensory deprivation b. registers nml body temperature c. pays attention to grooming d. obeys commands w appropriate motor responses D Q: A pt exhibiting an altered LOC due to blunt-force trauma to the head is admitted to the ED. The physician determines the pt's injury is causing increased ICP. The nurse should gauge the pt's LOC on the results of what diagnostic tool? a. Monro-Kellie hypothesis b. Glasgow Coma Scale c. Cranial nerve function d. mental status examination B Q: A pt w increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the pt is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? a. encephalitis b. CSF leak c. meningitis d. catheter occlusion C Q: The nurse is participating in the care of a pt w increased ICP. What diagnostic test is contraindicated in this pt's treatment? a. computed tomography (CT) scan b. lumbar puncture c. magnetic resonance imaging (MRI) d. venous doppler studies B Q: The nurse has created a plan of care for a pt who is at risk for increased ICP. The pt's care plan should specify monitoring for what early sign of increased ICP? a. disorientation and restlessness b. decreased pulse and respirations c. projectile vomiting d. loss of corneal reflex A Q: The neurologic ICU nurse is admitting a pt following a craniotomy using the supratentorial approach. How should the nurse best position the pt? a. position the pt supine b. maintain HOB elevated at 30-45 degrees c. position pt in prone position d. maintain bed in Trendelenberg position B Q: A pt has developed diabetes insipidness after having increased ICP following head trauma. What nursing assessment best addresses this complication? a. vigilant monitoring of fluid balance b. continuous BP monitoring c. serial arterial blood gases (ABGs) d. monitoring of the pt's airway for patency A Q: What would the nurse suspect when hourly assessment of UO on a pt postcrainiotomy exhibits a urine output from a catheter of 1,500mL for 2 consecutive hours? a. ruching syndrom b. syndrome of inappropriate antidiuretic hormone (SIADH) c. adrenal crisis d. diabetes insipidus D Q: During the exam of an unconscious pt, the nurse observes that the pt's pupils are fixed and dilated. What is the most plausible clinical significant of the nurses finding? a. it suggests onset of metabolic problems b. it indicates paralysis on the right side of the body c. it indicates paralysis of cranial nerve X d. it indicates an injury at the midbrain level D Q: Following a traumatic brain injury, a pt has been in a coma for several days. Which of the following statements is true of this pt's current LOC? a. the pt occasionally makes incomprehensible sounds b. the pt's current LOC will likely become a permanent state c. the pt may occasionally make non purposeful movements d. the pt is incapable of spontaneous respirations C Q: The nurse is caring for a pt w permanent neurologic impairments resulting from a traumatic head injury. When working w this pt and family, what mutual goal should be prioritized? a. achieve as high a level of function as possible b. enhance the quantity of the pt's life c. teach the family proper care of the pt d. provide community assistance A Q: The nurse is caring for a pt whose recent health hx includes an altered LOC. What should be the nurses first action when assessing this pt? a. assessing the pt's verbal response b. assessing the pt's ability to follow complex commands c. assessing the pt's judgment d. assessing the pt's response to pain A The nurse for a pt in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply: a. contractures b. hemorrhage c. pressure ulcers d. venous thromboembolism e. pneumonia A, C, D, E The nurse is caring for a pt w a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? a. solumedrol b. dextromethorphan c. dexamethasone d. furosemide C The nurse is caring for a pt who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the pt's respiratory effort has increased. What is the nurses most appropriate response? a. inform the care team and assess for further signs of possible increased ICP b. administer bronchodilators and monitor the pt's LOC c. increase the pt's bed height and reassess in 30 mins d. administer a bolus of normal line as ordered A A pt has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the pt's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? a. hemiplegia b. dry mucous membranes c. signs of internal bleeding d. loss of brain stem reflexes D When caring for a pt w increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the pt developed SIADH? a. fluid restriction b. transfusion of platelets c. transfusion of fresh frozen plasma (FFP) d. electrolyte restriction A A pt is recovering from an intracranial surgery performed approximately 24 hrs ago and is complaining of a headache that the pt rates at 8 on a 10-point pain scale. What nursing action is most appropriate? a. administer morphine sulfate as ordered b. reposition the pt in a prone position c. apply a hot pack to the pt's scalp d. implement distraction techniques A A pt is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the LOC is slightly decreased w the day of surgery. What is the nurses best response to this assessment finding? a. recognize that this may represent the peak of post-surgical cerebral edema b. alert the surgeon to the possibility of an intracranial hemorrhage c. understand that the surgery may have been unsuccessful d. recognize the need to refer the pt to the palliative care team A A pt w a cerebral aneurysm exhibits s/s of an increase in ICP. What nursing intervention would be the most appropriate for this pt? a. ROM exercises to prevent contractors b. encouraging independence w ADLs to promote recovery c. early initiation of physical therapy d. absolute bed rest in a quiet, non stimulating environment D A pt has been admitted to the ICU after being recently diagnosed w an aneurysm and the pt's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the pt's plan of care? a. elevate the HOB to 45 degrees b. maintain the pt on complete bed rest c. administer enemas when the pt is constipated d. avoid use of thigh-high elastic compression stockings B A pt diagnosed w a cerebral aneurysm reports a severe HA to the nurse. What action is a priority for the nurse? a. sit w the pt for a few minutes b. administer an analgesic c. inform the nurse-manager d. call the physician immediately D When caring for a pt who has had a stroke, a priority is reduction of ICP. What pt position is most consistent w this goal? a. head turned slightly to the R side b. elevation of HOB c. position changes q15min while awake d. extension of neck B After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action a. administer a bolus of normal saline as ordered b. prepare pt for thrombolytic therapy as ordered c. facilitate testing for hypothalamic dysfunction d. prepare to administer 3% NaCl by IV as ordered D Following diagnostic testing, a pt has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in pt's plan of care? a. supervise the pt's activities of daily living closely b. initiate early ambulation to prevent complications of immobility c. provide a high-calorie, low-protein diet d. perform all of the pt's hygiene and feeding A A pt is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hour ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing dx should the nurse associate w this procedure? a. risk for impaired skin integrity b. risk for injury c. risk for autonomic dysreflexia d. risk for suffocation B A nurse is caring for a critically ill pt w autonomic dysreflexia. What clinical manifestations would the nurse expect in this pt? a. respiratory distress & projectile vomiting b. bradycardia & HTN c. tachycardia & agitation d. third-spacing & hyperthermia B The nurse is caring for a pt w increased ICP caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the pt may be experiencing increased brain compression causing brains temp damage? a. hyperthermia b. tachycardia c. HTN d. bradypnea A A pt is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the pt fell, she was knocked out, but came back and seemed okay. Now she is c/o a severe HA and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? a. insertion of an intracranial monitoring device b. treatment w antihypertensives c. emergency craniotomy d. administration of anticoagulant therapy C The staff educator is precasting a nurse new to the critical care unit when a pt w a T2 spinal cord injury is admitted. The pt is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the pt closely, what would be the nurses most appropriate action? a. prepare to transfuse packed red blood cells b. prepare for interventions to increase the pt's BP c. place the pt in the Trendelenberg position d. prepare an ice bath to lower core body temperature B An ED nurse has just received a call from EMS that they are transporting a 17 y/o man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? a. sports-related injuries b. acts of violence c. injuries due to a fall d. motor vehicle accidents D A pt w spinal cord injury has a nursing dx of altered mobility & the nurse recognizes the increased risk for DVT. Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? a. pacing the pt on a fluid restriction as ordered b. applying thigh-high elastic stockings c. administering an antifibriolyic agent d. assisting the pt w passive ROM exercises B Paramedics have brought an intubated pt to the ED following a head injury due to acceleration-deceleration MVA. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? a. keep HOB flat at all times b. teach pt to perform the Valsalva maneuver c. administer benzodiazepines on a PRN basis d. perform endotracheal suctioning every hour C A pt who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the pt's current health status is most likely to have precipitated this event? a. the pt received a blood transfusion b. the pt's analgesia regimen was recently changed c. the pt was not repositioned during the night shift d. the pt's urinary catheter became occluded D A pt is admitted to the neurologic ICU w a spinal cord injury. In writing the pt's care plan, the nurse specifies that contractures can be best prevented by what action? a. reposting pt q2hr b. initiating ROM as soon as the pt initiates c. initiating ROM exercises as soon as possible after injury d. perfuming ROM exercises one a day C A pt w a head injury had been increasingly agitated & the nurse has consequently identifies a risk for injury. What is the nurses best intervention for preventing injury? a. restrain the pt as ordered b. administer opioids PRN as ordered c. arrange for friends & family members to sit w the pt d. pad the side rails of the pt's bed D A pt w a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the pt c/o sever throbbing HA. What should the nurse do first? a. check the pt's indwelling urinary catheter for kinks to ensure patecny b. lower the HOB to improve perfusion c. administer analgesia d. reassure the pt that headaches are expected after spinal cord injuries A A pt is admitted to the neurologic ICU w a spinal cord injury. When assessing the pt the nurse notes there is a sudden depression fo reflex activity in the spinal cord below the level of injury. What should the nurse suspect? a. epidural hemorrhage b. hypertensive emergency c. spinal shock d. hypovolemia C An elderly woman found w a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment w no neck flexion or head rotation; avoid sharp hip flexion? a. to decrease cerebral arterial pressure b. to avoid impeding venous outflow c. to prevent flexion contractures d. to prevent aspiration of stomach contents B A pt w a T12 is in spinal shock. The nurse will expect to observe what assessment finding? a. absence of reflexes along w flaccid extremities b. positive Babinskis reflex along w spastic extremities c. hyperreflexia along w spastic extremities d. spasticity of all 4 extremities A A nurse is reviewing the trend of a pt's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the pt's status? a. reflex activity b. level of consciousness c. cognitive ability d. sensory involvement B The nurse is caring for a pt who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply. a. absence of pain response b. apnea c. coma d. absence of brain stem reflexes e. absence of deep tendon reflexes B, C, D Following a SCI a pt is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? a. compete the pin site care to decrease risk of infection b. notify the neurosurgeon of the occurrence c. stabilize the head in a lateral position d. reattach the pin to prevent further head trauma B The ED is notifies that a 6 y/o is in transit w a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? a. promote adequate circulation b. treating the child's increased ICP c. assessing secondary brain injury d. preserving brain homeostasis D An 82 y/o man is admitted for observation after a fall. Due to his age, the nurse knows that the pt is at increased risk for what complication of his injury? a. hematoma b. skull fracture c. embolus d. stroke A A neurologic flow chart is often used to document the care of a pt w a traumatic brain injury. At what point in the pt's care should the nurse begin to use a neurologic flow chart? a. when the pt's condition begins to deteriorate b. as soon as the initial assessment is made c. at the beginning of each shift d. when there is a clinically significant change in the pt's condition B The nurse planning the care of a pt w head injuries is addressing the pt's nursing dx of sleep deprivation. What action should the nurse implement? a. administer a benzodiapine at bedtime each night b. do not disturb the pt between 2200 & 0600 c. cluster overnight nursing activities to minima disturbances d. ensure that the pt does not sleep during the day C The nurse has implemented interventions amend at facilitating family coping in the care of a pt w a traumatic brain injury. How can the nurse best facilitate family coping? a. help the family understand that the pt could've died b. empathize the importance of accepting the pt's new limitations c. have the members of the family plan the pt's inpatient care d. assist family in setting appropriate short-term goals D The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. a. young age b. frequent travel c. African American race d. male gender e. alcohol or drug use A, D, E The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? a. ensure that the player is not moved b. obtain the players vital signs, if possible c. perform a rapid assessment of the players ROM d. assess the player's reflexes A The nurse is caring for a pt whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this? a. Baclofen (Lioresal) b. Dexamethasone (Decadron) c. Mannitol (Osmitrol) d. Phenobarbital (Luminal) A The nurse is planning the care of a pt w a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk? a. change the patients position frequently b. provide a high-protein diet c. provide light massage at least daily d. teach the pt deep breathing & coughing exercises A A pt w a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the pt's risk for orthostatic hypotension? a. administer an IV bolus of normal saline prior to repositioning b. maintain bed rest until normal BP regulation returns c. monitor the pt's BP before & during position changes d. allow the pt to initiate repositioning C A nurse on the neurologic unit is providing care for a pt who has spinal cord injury at the level of C4. When planning the pt's care, what aspect of the pt's neurologic and functional status should the nurse consider? a. the pt will be unable to use a wheelchair b. the pt will be unable to swallow food c. the pt will be continent of urine, but incontinent of bowel d. the pt will require full assistance fo all aspects of elimination D The nurse is providing health education to a pt who has a C6 spinal cord injury. The pt asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer? a. the sudden increase in BP can raise the ICP or rupture a cerebral blood vessel b. the suddenness of the onset of the syndrome tells us the body is struggling to maintain its nml state c. autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing d. the sudden, severe headache increases muscle tone and can cause further nerve damage A The nurse is caring for a pt w a spinal cord injury notes that the pt is exhibiting early s/s of disuse syndrome. Which of the following is the most appropriate nursing action? a. limit the amount of assistance provided w ADLs b. collaborate w the physical therapist & immobilize the pt's extremities temporarily c. increase the frequency of ROM exercises d. educate the pt about the importance of frequent position changes C Splints have been ordered for a pt who is at risk of developing foot drop following a spinal cord injury. The nurse caring for this pt knows that the splints are removed and reapplied when? a. at the pt's request b. each morning and evening c. every 2 hours d. one hour prior to mobility exercises C A pt who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume nml elimination. What principle should guide the care teams decision regarding this intervention? a. urinary retention can have serious consequences in pt's w SCIs b. urinary function is permanent lost following and SCI c. urinary catheters should not remain in place for more than 7 days d. overuse of urinary catheters can exacerbate nerve damage A A pt w spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this pt? Select all that apply: a. orthostatic hypotension b. autonomic dysreflexia c. DVT d. salt-wasting syndrome e. increased ICP A, B, C The nurse recognizes that a pt w a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? a. position the pt in a high fowlers position when in bed b. support the knees w a pillow when the pt is in bed c. perform passive ROM exercises as ordered d. administer NSAIDs as ordered C A pt is admitted to the neurologic ICU w a C4 spinal cord injury. When writing the plan of care for this pt, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this pt? a. risk for impaired skin integrity r/t immobility & sensory loss b. impaired physical mobility r/t loss of motor function c. ineffective breathing patterns r/t weakness of the intercostal muscles d. urinary retention to inability to void spontaneously C A pt w possible bacterial meningitis is admitted to the ICU, What assessment finding would the nurse expect for a pt w this diagnosis? a. pain upon ankle dorsiflexion of the foot b. neck flexion produces flexion of knees and hips c. inability to stand w eyes closed and arms extended w/o swaying d. numbness & tingling in the lower extremities B A pt w Guillain-Barr syndrome has experiences a sharp decline in vital capacity. What is the nurses most appropriate action? a. administer bronchodilators as ordered b. remind the pt of the importance of deep breathing and coughing exercises c. prepare to assist w intubation d. administer supplementary oxygen by nasal cannula C A male pt presents to clinic c/o headache. The nurse notes that the pt is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the pt may have meningitis. What is another well-recognized sign of this infection? a. negative Brudzinskis sign b. positive Kernigs sign c. hyper patellar reflex d. sluggish pupil reaction B The nurse is caring for a pt diagnosed w Guillain-Barr syndrome is planning care w regard to the clinical manifestations associated w this syndrome. The nurses communication w the pt should reflect the possibility of what sign or sx of the ds? a. intermittent hearing loss b. tinnitus c. tongue enlargement d. vocal paralysis D The nurse is preparing to provide care for a pt diagnosed w myasthenia gravis. The nurse should know that the s/s of the ds are the result of what? a. genetic dysfunction b. upper and lower neuron lesions c. decreased conduction of impulses in an upper motor neuron lesion d. a lower motor neuron lesion D A pt w herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the physician to order for the treatment of this ds process? a. cyclosporine (Neoral) b. acyclovir (Zovirax) c. cyclobenzaprine (Flexeril) d. ampicillin (Prinicpen) B A nurse is planning the care of a 28y/o woman hospitalized w a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this pt? a. all at one time, to provide a longer rest period b. before meals, to stimulate her appetite c. in the morning, w frequent rest periods c. before bedtime, to promote rest C The nurse is developing a plan of care for a pt w Guillain-Barr syndrome. Which of the following interventions should the nurse prioritize for this pt? a. using the incentive spirometer as prescribed b. maintaining the pt on bed rest c. providing aids to compensate for loss of vision d. assessing frequently for loss of cognitive function A A 69 y/o pt is brought to the ED bc a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial meningitis & admits the pt to the ICU. The nurse knows that risk factors for an unfavorable outcome include what? Select all that apply: a. BP greater than 140/90 mm Hg b. HR greater than 120 bpm c. older age d. low Glasgow scale e. lack of previous immunizations B, C, D The critical care nurse is caring for a 25 y/o man admitted to the ICU w a brain abscess. What is a priority nursing responsibility in the care of the pt? a. maintaining the pt's functional independence b. providing health education c. monitoring neurologic status closely d. promoting mobility C A pt is being admitted to the neurologic ICU w suspected herpes simplex virus encephalitis. What nursing action best addresses the pt's complaints of headache? a. initiating a patient-controlled analgesia (PCA) of morphine sulfate b. administering hydromorphone (Dilaudid) IV as needed c. dimming the lights and reducing stimulation d. distracting the pt w activity C A pt is admitted through the ED w suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? a. serial assessments of hemoglobin levels b. blood glucose monitoring c. close monitoring of fluid balance d. assessment of pain along dermatomes C You are the clinic nurse caring for a pt w a recent diagnosis of myasthenia gravis. The pt has begun treatment w pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication? a. increased muscle strength b. decreased pain c. improved GI function d. improved cognition A The critical care nurse is admitting a pt in myasthenia crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this pt? a. suctioning secretions b. facilitating ABG analysis c. providing ventilatory assistance d. administering tube feedings C The nurse caring for a pt in pt in ICU diagnosed w Guillain-Barr syndrome should prioritize monitoring for what potential complication? a. impaired skin integrity b. cognitive deficits c. hemorrhage d. autonomic dysfunction D The nurse is teaching a pt w Guillain-Barr syndrome about the ds. The pt asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurses best response? a. Guillain-Barr spares the Schwann cell, which allows for demyelination in the recovery phases of the ds b. in Guillain-Barr, Schwann cells replicate themselves before the ds destroys them, so demyelination is possible c. I know understand that never cells do not demyelinate, so the physician is the best one to answer your question d. for some reason, in Guillain-Barr, Schwann cells become activated and take over the demyelination process A A pt diagnosed w myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a pt w myasthenia gravis is what? a. every day for 1 week b. determined by the pt's response c. alternate days for 10 days d. determined by the pt's weight B a pt presents to the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what? a. Guillain-Barr syndrome b. Myasthenia gravis c. trigeminal neuralgia d. peripheral nerve disorder D A nurse in the ICU is planning the care of a pt who is being treated for shock. Which of the following statements best describes the pathophysiology of this pt's health problem? a. blood is shunted from vital organs to peripheral areas of the body b. cells lack an adequate blood supply and are deprived of oxygen and nutrients c. circulating blood volume is decreased w a resulting change in the osmotic pressure gradient d. hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion B In an acute care setting, a nuse is assessing an unstable pt. When prioritizing the pt's care, the nurse should recognize that the pt is at risk for hypovolemic shock in which of the following circumstances? a. fluid volume circulating in the blood vessels decreases b. there is an uncontrolled increase in cardiac output c. blood pressure regulation becomes irregular d. the pt experiences tachycardia and a bounding pulse A The emergency nurse is admitting a pt experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent w the early stage of compensation? a. increased urine output b. decreased HR c. hyperactive bowel sounds d. cool, clammy skin D The nurse is caring for a pt who is exhibiting s/s of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock? a. lactated ringers b. albumin c. dextran d. 3% NaCl A A pt who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurses care planning during the administration of a vasoactive drug? a. the drug should be discontinued immediately after BP increases b. the drug dose should be tapered down once vital signs improve c. the pt should have arterial blood gases drawn every 10 mins during treatment d. the infusion rate should be titrated according to the pt's subjective sensation of adequate perfusion B A nurse in the ICU receives report from the nurse in the ED about a new pt being admitted w a neck injury he received while diving into a lake. The ED nurse reports that his BP is 85/54, heart rate is 53 beats/min, and his skin is warm and dry. What does the ICU nurse recognize that the pt is probably experiencing? a. anaphylactic shock b. neurogenic shock c. septic shock d. hypovolemic shock B The intensive care nurse caring for a pt in shock is planning assessments and interventions r/t the pt's nutritional needs. What physiologic process contributes to these increased nutritional needs? a. the use of albumin as an energy source by the body bc of the need for increased adenosine triphosphate (ATP) b. the loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity c. the release of catecholamines that creates an increase in metabolic rate and caloric requirements d. the increase in GI peristalsis during shock and the result diarrhea C The nurse is transferring a pt who is in the progressive stage of shock into ICU from the medical unit. The medical nurse is aware that shock affects many organ systems and that nursing management of the pt will focus on what intervention? a. reviewing the case of shock and prioritizing the pt's psychosocial needs b. assessing and understanding shock and the significant changes in assessment data to guide the plan of care c. giving the prescribed treatment, but shifting focus to providing family time as the pt is unlikely to survive d. promoting the pt's coping skills in an effort to better deal w the physiologic changes accompanying shock B When caring for a pt in shock, one of the major nursing goals is to reduce the risk that the pt will develop complications of shock. How can the nurse best achieve this goal? a. provide a detailed diagnosis and plan of care in order to promote the pt's & family's coping b. keep the physician updated w the most accurate info bc in cases of shock the nurse cannot provide relevant interventions c. monitor for significant changes and evaluate pt outcomes on a scheduled basis focusing on BP & skin temp d. understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment D The acute care nurse is providing care for an adult pt who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe r/t the role of the ADH during hypovolemic shock? a. increased hunger b. decreased thirst c. decreased urinary output d. increased capillary perfusion C The nurse caring for a pt whose progressing infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock? a. elevated systolic BP b. elevated mean arterial pressure (MAP) c. shallow, rapid respirations d. bradycardia C You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a pt who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the pt? a. hypothermia b. Bradycardia c. coffee ground emesis d. pain A The nurse is caring for a pt in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications? a. frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration b. reviewing medications, performing a focused cardiovascular assessment, and proving patient education c. reviewing the lab findings, monitoring urine output, and assessing for peripheral edema d. routing monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions A The nurse in the ICU is admitting a 57 y/o man w a diagnosis of possible septic shock. The nurses assessment reveals that the to has a nml BP, increased HR, decreased bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary conclusion? a. the pt is in the compensatory stage of shock b. the pt is in the progressive stage of shock c. the pt will stabilize and be released by tomorrow d. the pt is in the irreversible stage of shock A The nurse, a member of the healthcare team in the ED, is caring for a pt who is determines to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? a. provide opportunities for the family to spend with the pt, and help them to understand the irreversible stage of shock b, inform the pt's family immediately that the pt will likely not survive to allow the family time to make plans and move forward c. closely monitor fluid replacement therapy, and form the family and the pt will probably survive and return to nml life d. protect the patients airway, optimize intravascular volume, and intimate the early rehabilitation process A The nurse in a rural nursing output has just been notified that she will be receiving a pt in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. You know that the best choice for fluid replacement for this pt is what? a. 5% albumin bc it is inexpensive and is always really available b. Dextran bc it increases intravascular volume and counteracts coagulopathy c. Whatever fluid is most readily available in the clinic, due to the nature of the emergency d. lactated ringers solution bc it increases volume, buffers acidosis, and is the best choice for pt's w liver failure C The nurse in the ICU is caring for a 47-year-old, obese male patient who is in shock following a motor vehicle accident. The nurse is aware that patients in shock possess excess energy requirements. What would be the main challenge in meeting this patients elevated energy requirements during prolonged rehabilitation? a. loss of adipose tissue b. loss of skeletal muscle c. inability to covert adipose tissue to energy d. inability to maintain nml body mass B The nurse in the ED is caring for a pt recently admitted w a likely MI. The nurse understands that the pt's heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess? a. dysrhythmias b. increase in BP c. increase in HR d. decrease in oxygen demands A The nurse is caring for a pt admitted w cariogenic shock. The pt is experiencing CP & there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this pt? a. it promotes coping & slows catecholamine release b. it stimulates the pt so he/she is more alert c. it decreases gastric secretions d. it dilates blood vessels D The nurse is providing care for a pt who is in shock after massive blood loss from a workplace injury, The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states? a. third spacing of fluid b. dysrhythmias c. tachycardia d. gastric hypermotility C The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply. a. drop in systolic BP of 40 mm Hg from baselines b. hypotension that responds to bolus of fluid resuscitation c. exaggerated response to vasoactive meds d. serum lactate 4mmol/L e. mean arterial pressure (MAP) of 65 mm Hg A, D, E An adult patient has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this patient. What aspect of his care should be prioritized by the home health nurse? a. providing supervision to home health aides in providing necessary pt care b. assisting the pt and family to identify & mobilize community resources c. providing ongoing medical care during the family rehab phase d. reinforcing the importance of continuous assessment w the family B A critical care nurse is aware of similarities and differences between the treatments for different types of shock. Which of the following interventions is used in all types of shock? a. agressive hypoglycemic control b. administration of hypertonic IV fluids c. early provision of nutritional support d. agressive antibiotic therapy C In all types of shock, nutritional demands increase rapidly as the body depletes its stores of glycogen. Enteral nutrition is the preferred method of meeting these increasing energy demands. What is the basis for enteral nutrition being the preferred method of meeting the body's needs? a. it slows the proliferation of bacteria & viruses during shock b. it decreases the energy expended through the functioning of the GI system c. it assists in expanding the intravascular volume of the body d. it promotes GI function through direct exposure to nutrients D The ICU nurse is caring for a patient with multiple organ dysfunction syndrome (MODS) due to shock. What nursing action should be prioritized at this point during care? a. providing info and support to family members b. preparing the family for a long recovery process c. educating the pt regarding the use of supportive fluids d. facilitating the rehab phase of treatment A A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply. a. hypovolemia b. difficulty breathing c. cardiovascular overload d. pulmonary edema e. hypoglycemia B, C, D When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the periphery of the body. An ICU nurse caring for a patient in circulatory shock should know that the pooling of blood in the periphery leads to what pathophysiological effect? a. increased stroke volume b. increased CO c. increased HR d. decreased venous return D A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply. a. anaphylactic b. hypovolemic c. cardiogenic d. septic e. neurogenic A, D, E A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boys mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock? a. rapid onset of acute hypertension b. rapid onset of respiratory distress c. rapid onset of neurologic compensation d. rapid onset of cardiac arrest B The ICU nurse is caring for a patient in neurogenic shock following an overdose of antianxiety medication. When assessing this patient, the nurse should recognize what characteristic of neurogenic shock? a. HTN b. cool, moist skin c. bradycardia d. signs of sympathetic stimulation C The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? a. to prevent the formation of infarcts of emboli b. to limit stroke volume & cardiac output c. to prevent pulmonary & peripheral edema d. to maintain adequate mean arterial pressure D The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The nurse should know that vasoactive medications should be administered in what way? a. through a central venous line b. by a gravity infusion IV set c. by IV push for rapid onset of action d. mixed w parenteral feedings to balance osmosis A The ICU nurse is caring for a patient in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the patient? a. anaphylaxis b. decreased oxygen consumption c. abdominal compartment syndrome d. decreased serum osmolality C A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the patients care? a. communicate clearly & frequently w the pt's family b. taper down interventions slowly when the prognosis worsens c. transfer the pt to a subacute unit when recovery appears unlikely d. ask the pt's family how they would prefer treatment to proceed A A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patients plan of care while the patient is ventilated? a. performing frequent oral care b. maintinas pt in supine position c. suctioning pt q15mins unless contraindicated d. administering prophylactic abx, as ordered A A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the patients mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply. a. Blood urea nitrogen (BUN) level b. urine specific gravity c. alkaline phosphatase level d. creatinine level e. serum albumin level A, B, D An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patients infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patients risk of septic shock? a. apply an antibiotic ointment to the pt's mucous membranes, as ordered b. perform passive ROM exercises unless contraindicated c. initiate total parenteral nutrition (TPN) d. remove invasive devices as soon as they are no longer needed D A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care? a. the increase in cultural diversity in the US b. staffing shortages in healthcare and questions concerning quality of care c. increased costs of healthcare coupled w inequalities in access d. ability of technology to prolong life beyond meaningful quality of life D The nurse is caring for a patient who has been recently diagnosed with late stage pancreatic cancer. The patient refuses to accept the diagnosis and refuses to adhere to treatment. What is the most likely psychosocial purpose of this patients strategy? a. the pt may be trying to protect loved ones from he motional effects of the illness b. the pt is being noncompliant in order to assert power over caregivers c. the pt may be skeptical of the benefits of the Western biomedical model of health d. the pt thinks that tx does not provide him comfort A An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? a. the pt & family should be viewed as a single unit of care b. persistent sx of terminal illness should be treated c. each member of the interdisciplinary team should develop an individual plan of care d. terminally ill pt's should die in the hospital whenever possible A A clinic nurse is providing patient education prior to a patients scheduled palliative radiotherapy to her spine. At the completion of the patient teaching, the patient continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from this? a. the pt is not listening effectively b. the pt is noncompliant w the plan of care c. the pt may have low intelligence quotient or a cognitive deficit d. the pt has not achieved the desire learning outcomes D The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond? a. privately ask the son to allow the pt to make his own healthcare decisions b. explain to the pt that he is responsible for his own decisions c. work w the team to negotiate informed consent d. avoid divulging info to the eldest son C One aspect of the nurses comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category? a. uplifting memories b. ignoring negative outcomes c. envisioning one specific outcome d. avoiding any actual or potential threat A A patients rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patients care, the nurse should identify what primary aim? a. To prioritize emotional needs b. To prevent and relieve suffering c. To bridge between curative care and hospice care d. To provide care while there is still hope B A patient with end-stage heart failure has participated in a family meeting with the interdisciplinary team and opted for hospice care. On what belief should the patients care in this setting be based? A) Meaningful living during terminal illness requires technologic interventions. B) Meaningful living during terminal illness is best supported in designated facilities. C) Meaningful living during terminal illness is best supported in the home. D) Meaningful living during terminal illness is best achieved by prolonging physiologic dying. C A nurse who provides care on an acute medical unit has observed that physicians are frequently reluctant to refer patients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply. A) Financial pressures on health care providers B) Patient reluctance to accept this type of care C) Strong association of hospice care with prolonging death D) Advances in curative treatment in late-stage illness E) Ease of making a terminal diagnosis A, B, D The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care? A) Aggressively continuing to fight the disease process B) Moving the patient to a long-term care facility when it becomes necessary C) Including the children in planning their fathers care D) Supporting the patients and familys values and choices D A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness D The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation C A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis A A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat B n occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patients affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently. D An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? A) The length of time since the burn B) The location of burned skin surfaces C) The source of the burn D) The total body surface area (TBSA) affected by the burn D A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) 1 week A A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care? A) Fluid status B) Risk of infection C) Nutritional status D) psychsocial coping A The nurse is preparing the patient for mechanical dbridement and informs the patient that this will involve which of the following procedures? a. A spontaneous separation of dead tissue from the viable tissue b. Removal of eschar until the point of pain and bleeding occurs c. Shaving of burned skin layers until bleeding, viable tissue is revealed d. Early closure of the wound B A patient is brought to the ED by paramedics, who report that the patient has partial- thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management D A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? A) 13% B) 25% C) 9% D) 18% D A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A) Sodium deficit B) Decreased prothrombin time (PT) C) Potassium deficit D) decreased hematocrit A A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification c A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response? A) Perform mechanical dbridement to remove the exudate and prevent further infection. B) Inform the primary care provider promptly because the graft may need to be removed. C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D) Document this finding as an expected phase of graft healing. B A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member? A) Hes on a calorie-restricted diet in order to divert energy to wound healing. B) His body has consumed his fat deposits for fuel because his calorie intake is lower than normal. C) He actually hasnt lost weight. Instead, theres been a change in the distribution of his body fat. D) He lost many fluids while he was being treated in the emergency phase of burn care. B A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female patient burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire A A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Gastrointestinal hypermotility C) Respiratory arrest D) Hypokalemia A A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? A) Confusion B) High fever C) Decreased blood pressure D) Sudden agitation C An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patients body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) administer broad-spectrum abs C) administer IV potassium chloride D) Administer packed RBCs A A patients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? a. 0.45% NaCl with 20 mEq/L KCl b. 0.45% NaCl with 40 mEq/L KCl c. Normal saline d. Lactated Ringers D A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication? a. Ischemia b. Referred pain c. Cellulitis d. venous thromboembolism (VTE) A A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A) Obtain an order to reduce the rate of the patients IV fluid infusion. B) Report the patients early signs of acute kidney injury (AKI). C) Recognize that the patient is experiencing an expected onset of diuresis. D) Administer sodium chloride as ordered to compensate for this fluid loss. C A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the patient to keep the wound site in a dependent position. B) Administer PRN analgesia as ordered. C) Assess the patients peripheral pulses distal to the dressing. D) Assist with passive range of motion exercises to set the new dressing. C A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A) Maintenance of bed rest to aid healing B) Choosing appropriate splints and functional devices C) Administration of beta adrenergic blockers D) Prevention of venous thromboembolism D A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. W