NSG 430/ NSG430 Adult Health Nursing II Complete Guide Exam 4 (2026/ 2027 Updated) Verified Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- GCU

NSG 430/ NSG430 Adult Health Nursing II Complete Guide Exam 4 (2026/ 2027 Updated) Verified Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- GCU Q. Professional nurses develop performance and quality improvement programs and conduct EBP improvement studies and research. Which statement is true about standards? ANSWER Standards essentially define quality, against which performance and outcomes are measured. Q. Which of the following describes ways in which nurse managers can create an environment devoted to health care safety? ANSWER Establishing a culture of safe, effective, patient-centered, timely, efficient, and equitable care. Q. Quality can be defined in which of the following ways (SATA) ANSWER When outcomes compare favorably with standards The measurement of effectiveness, efficiency, benefits, and appropriateness of care services When higher volume of procedures is associated with lower mortality Q. A number of industry based models for quality management and measurement have been adopted by the healthcare industry over the past two decades. The model that provides a holistic approach to enterprise transformation and focuses on stakeholder's value propositions.. ANSWER Lean enterprise Q. Healthcare quality and safety principles and practices form the foundation of any accessible, reliable care services. In establishing this foundation, which of the following statements helps guide it? ANSWER The importance is on outcomes rather than process and structure Q. An overarching organizational strategy to ensure accountability of all employees, to incorporate evidence based healthcare quality indicators, and to improve care delivered to various populations is best known as ANSWER A performance improvement program Q. Which of the following describe the four tenets embraced by members of the IOM Committee on Quality of Health Care in America and how these tenets incorporate into nursing practice? (SATA) ANSWER Nurses use standardization of processes when using nursing dx to identify issues with clients and using nursing interventions to identify best practice to improve client's status Nurses use assessments to collect pt data to dx problems and risk and to identify the state of optimal health care across the continuum Using the methodology of PDCA is like the nursing practice Q. Diversity assists with team effectiveness, improves retention of the best people, capitalizes on out of the box thinking, lays the groundwork for future business growth, and provides more supportive work environments. Which of these are benefits to the nursing workforce? ANSWER A diverse workplace allows synergy of diverse viewpoints to improve nursing's knowledge base and care strategies Q. Cultural differences are characteristics that define individuals beyond unique numbers and names. Which statement is true? ANSWER Cultural differences in ways of doing things and in beliefs about health and illness are learned and transmitted via cultural environments. Q. A deliberate and cognitive process of becoming responsive and sensitive to the client's culture, values, and learning to avoid imposing on them is: ANSWER cultural awareness Q. Management must understand and address aspects of generational workforce diversity. Which of the following statements best describes aspects of the generations? ANSWER Nexters can create solutions that other generations could not have imagines. X'ers prefer a balanced life and protect themselves from the capriciousness of business challenges, constraints, and rules. Boomers ignore or break rules and will still be successful. The Silent Gen treasters and exhibits conformity. Q. Vasopressors may be used in the treatment of shock. Explain why. ANSWER vasopressors are a class of drug that induce vasoconstriction and increase the MAP In shock MAP is insufficient to maintain adequate tissue perfusion Q. While monitoring Ms. B's ABGs, the nurse notes that her PaO2 is 60 mmHg and her PaCO2 is 50 mmHg. What do these findings indicate, and why have they occurred? ANSWER note: previous lab data - pt is in respiratory alkalosis Hypovolemic shock body's compensatory mechanisms lead to changes in ABGs, as shock progresses, respiratory compensation fails as the number of alveoli that are perfused decreases and gas exchange is impaired the result is a decrease in PaO2 level and an increase in PaCO2 level Q. Ms. B has been given large amounts of colloids IV. Hemodynamic monitoring indicates higher-than-normal central venous pressure and pulmonary artery pressure. What do these findings indicate? ANSWER in pts w/shock who are receiving IV colloids, slighltly higher than normal CVP and PAO measurements are sometimes desirable and may indicate that vascular volume is being restored Q. You're working on a neuro unit. Which of your pts below are at risk for developing neurogenic shock? SATA a. 36 yo w/SCI at L4 b. 42 yo w/spinal anesthesia c. 25 yo w/SCI above T6 d. 55 yo who reports seeing green halos while taking digoxin ANSWER b. 42 yo w/spinal anesthesia c. 25 yo w/SCI above T6 any pt who has had cervical or upper thoracic SCI, receiving spinal anesthesia , or taking drugs to affect ANS or SNS is at risk Q. T/F: the PNS loses the ability to stimulate nerve impulses in pts who are experiencing neurogenic shock. This leads to hemodynamic changes ANSWER FALSE the SNS loses the ability to stimulate nerve impulses in pts who are experiencing neurogenic shock Q. A 42 yo male pt is admitted with SCI. The pt is experiencing severe hypotension and bradycardia. The pt is dx w/neurogenic shock. Why is hypotension occurring in this pt w/neurogenic shock the pt's ANS has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring ANSWER the vessels are relaxed and this causes massive vasodilation. Systemic vascular resistance will decrease and hypotension will occur Q. You receive a pt in the ER who has sustained a cervical SCI. You know this pt is at risk for neurogenic shock. What hallmark s/s, if experienced by this pt, would indicate the pt is expereincing neurogenic shock? SATA a. BP 69/38 b. HR 170bpm c. BP 250/120 d. HR 29 e. warm and dry extremities f. cool and clammy extremities g. temp 104.9F h. temp 95F ANSWER a, d, e, h Hallmark s/s of neurogenic shock: hypotension, bradycardia, hypothermia, warm/dry extremities (d/t vasodilation and blood pooling) Q. In neurogenic shock, a pt will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanims, in regard to pathophysiology, of why this is occurring? a. loss of vasomotor tone b. incr SVR c. decrease in cardiac preload d. increase in cardiac afterload e. decrease in venous blood return to the heart f. venous blood pooling in the extremities ANSWER a, c, e, f massive vasodilation is occurring in the body and this is d/ the loss of vasomotor tone. This will DECREASE SVR and BP will fall. There is pooling of venous blood in the extremities bc there isnt any pressure to push it back to the heart = decr in venous blood return to the heart. When this occurs it will decrease cardiac preload. Q. Youre providing care to a pt experiencing neurogenic shock d/t an injury at T4. As the nurse, you know what is a pt safety priority? ANSWER keeping the pt's spine immobilized want to prevent further damage or perfusion issues to the spinal cord Q. A pt in neurogenic shock is ordered IV fluids d/t severe hypotension. During administration of the fluids the nurse iwll monitor the pt closesly and immediately report? a. increase in BP b. high CVP and PAWP c. UO of 300 mL in the past 5hrs d. MAP 85 mmHg ANSWER B. High CVP and PAWP this would indicate the pt is in fluid volume overload. If fluids are ordered to help increase the BP, they should be used w/extreme caution bc fluid overload can occur -w/neuro shock pts usually have normal BP Q. A pt w/neurogenic shock is experiencing a HR of 30 bpm. What medication does the nurse antificpate will be ordered by the physician STAT? atropine ANSWER this will quickly incr the HR and block the effects of the parasympathetic system on the body Q. Your pt in neurogenic shock is not responding to IV fluids. The pt is started on vasopressors. What option below, if found in your pt, would indicate the med is working? a. decreased CVP b. MAP 90 c. serum lactate 6mmol/L d. blood pH 7.20 ANSWER b. MAP 90 MAP of 85-90mmHg will help maintain tissue perfusion and indicates the vasopressor is working to maintain tissue perfusion. It does this by causing vasoconstriction You're developing a nursing plan of care for pt w/neurogenic shock. As the nurse, you know that d/t venous blood pooling from vasodilation a DVT can occur in this type of shock. A pt goal is that the pt will be free from the development of a DVT. Select all the nursing interventions below that can help the pt meet this goal: a. perform ROM exercises daily b. place pillow underneath pt knees prn c. administer anticoagulants as scheduled per physician's order d. apply compression stockings daily A, C, D option b is not correct bc it would impede blood flow and incr the risk of DVT. The correct answers help prevent DVT Your pt is having a sudden and severe anaphylactic reaction to a medication. You immediately stop the meidcation and call a rapid response. The pt's BP is 80/52, HR 120, Sp02 87%. Audible wheezing is noted along w/facial redness and swelling. As the nurse you know that the first initial treatment for this pt's condition is? IM epinephrine IM or SQ epi is 1st line treatment Epinephrine will cause vasoconstriction (increase BP/decrease swelling) and bronchodilation (dilate airways). Epi will provide fast relief w/ anaphylaxis A 25yo female is admitted to the ER in anaphylactic shock d/t a bee sting. According to the pt's mother, the pt is severely allergic to bees and was recently stung by one. This type of anaphylactic reaction is known as? Type I Hypersensitivity Reaction this reaction is immediate and cause anaphylaxis. It occurs when an antigen attaches to immunoglobulin E (IgE) antibodies. Leads to system-wide release of inflammatory mediators During anaphylactic shock the mast cells and basophils release large amounts of histamine. What effects does histamine have on the body during anaphylactic shock? SATA a. decreases capillary permeability b. vasodilation of vessels c. decreases HR d. shifts intravascular fluid to interstitial space e. constricts the airways f. stimulates contraction of GI smooth muscles g. inhibits the production of gastric secretions h. itching b, d, e, f, h histamine INCREASES capillary permeability by shifting intravascular fluid to the interstitial space You're providing education to a pt, who has severe peanut allergy, on how to recognize the s/s of anaphylactic shock. Select all the s/s associated w/anaphylactic shock a. hyperglycemia b. difficulty speaking c. feeling dizzy d. HTN e. dyspnea f. itchy g. vomiting and nausea h. fever i. slow HR b, c, e, f, g pts who are in anaphylactic shock will have s/s associated with the effects of histamine. Histamine affects the respiratory, cardiac, GI and skin Your pt is started on an IV antibiotic to treat a severe infection. During infusion, the pt uses the call light to notify you that she feels a tight sensation in her throat and it's making it hard to breathe. You immediately arrive to the room and assess the pt. While ausculatating the lungs you note wheezing. You also notice the pt is starting to scratch the face and arms, and on closer inspection of the face you note redness and swelling that extends down to the neck and torso. The pt's VS are: BP 89/62, HR 118, Sp02 88% RA. You suspect anaphylactic shock. What are the appropriate interventions for this pt call rapid response place pt on oxygen prepare for the administration of epinephrine stop the infusion -epi increases BP, decr swelling, dilates the airway A pt is in anaphylactic shock. The pt has severe allergy to peanuts and mistakenly consumed an eggroll containing peanut ingredients during his lunch break. The pt is given epinephrine IM. As the nurse you know this medication will have what effect on the body? it will help dilate the airways -acts as a vasopressor and will actually dilate the airway -epi performs vasoconstriction which will INCREASE BP You're providing care to a pt in anaphylactic shock. What is NOT a typical medical treatment for this condition, and if ordered the nurse should ask for an order clarification? a. IV diphenhydramine b. epinephrine c. corticosteroids d. isotonic IV fluids e. IV furosemide e. IV furosemide -loop diuretic which removes extra fluid from the blood volume. Pts w/this condition actually need fluids bc of the shift of fluid from the intravascular space to the interstitial space You're assessing a pt's knowlege on how to use their EpiPen in case of an anaphylactic reaction. You're using an EpiPen trainer device to teach the pt. What demonstrated by the pt shows the pt knows how to administer the medication? SATA a. pt injects the med in the SQ tissue of abd b. pt massages the site after injection c. pt administers injection through clothes d. pt aspirates before injecting the medication b, c EpiPen is auto-injector that is administered in middle of outer thigh, pt should massage site for 10 sec after administration to increase absorption what is the MOST important step a nurse can take to prevent anaphylactic shock in a pt assess, document, and avoiding all the pt allergies a pt is having an anaphylactic reaction to an IV medication. What is the FIRST action the nurse should take? stop the medication want to immediately remove the allergen, then call a rapid response, maintain airway and start CPR if needed until help arrives what is the BEST position for a pt in anaphylactic shock? supine w/legs elevated this will increase venous return to the heart, which will help increase CO and BP T/F: septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body FALSE there is a DECREASE SVR in septic shock d/t vasodilation. In septic shock, vasodilation is system wide A pt is diagnosed w/septic shock. As the nurse you know this is a _____ form of shock. In addition, you're aware that ______ and ______ are also this form of shock distributive; anaphylactic and neurogenic septic: there is an issue w/distribution of blood flow in small blood vessels of body. This shock isnt occurring d/t an issue w/CO, which occurs in hypovolemic and cardiogenic shock Your pt, who is post-op from a GI surgery, is presenting w/temp of 103.6F, HR 120, BP 72/42, incr WBC, RR 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the pt is progressing to septic shock? SATA: a. BP of 70/34 after the fluid bolus b. serum lactate 2mmol/L c. pt needs norepinephrine to maintain a MAP 65 mmHg despite fluid replacement d. CVP of 18 a, c A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? Select all that apply: a. absolute hypovolemia b. vasodilation c. increased capillary permeability d. increased SVR e. clot formation in microcirculation f. a significantly decreased CO b, c, e setpic shoc occurs d/t sepsis -CO is not the problem in septic shock as w/other types of shcoks A pt is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? Bacteria g+ or g= bacteria are most common A pt w/fever is lethargic and has BP of 89/56. The pt's WBC is elevated. The physician suspects the pt is developing septic shock. What other findings indicate this pt is in the "early" or "compensated" stage of septic shock? SATA a. UO of 60mL over 4hrs b. warm and flushed skin c. tachycardia d. bradypnea b, c in septic shock vasodilation is occurring and this leads to WARM and FLUSHED skin in the early stage - late stage will be cool/clammy. Tachycardia and tachypnea occurs in the early stage too as a compensatory mechanism. Oliguria (option A) is in the late stage or uncompensated when the kidneys are starting to fail The physician orders a pt in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this pt? a. pt's BP changes from 75/48 to 110/82 b. CVP 2mmHg c. Skin is warm and flushed d. UO is 20mL/hr a. BP change 75/48 to 110/82 septic shock, first treatment is to try to maintain tissue perfusion w/fluids, if that doest work vasopressors A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT? norepinephrine 1. fluids ordered first 2. vasopressors second 3. norepi Your patient, who is post-op from a kidney transplant, has developed septic shock. What will you perform first? collect cultures and then administer IV abx A pt in septic shock is experiencing hyperglycemia. The pt is started on an insulin drip. A blood glucose goal for this pt would be: a. 110 b. 80 c. 200 d. 180 d. 180 hyperglycemia affects the immune system and healing Your pt's BP is 72/56, HR 126, RR 24. The pt has a fungal infection in the lungs. The pt also has a fever, warm/flushed skin, and restless. You notify the HCP who suspects septic shock. You anticipate that the physician will order what treatment first? crystalloids IV fluid bolus first treatment in regards to helping maintain tissue perfusion is fluid replacement w/either crystalloid or colloid solutions. THEN vasopressors like norepi are ordered if fluids dont help T/F: hypovolemic shock occurs where ther is low fluid volume in the intersitital compartment FALSE hypovolemic shock occurs where there is low fluid volume in the INTRAVASCULAR system As the nurse you know that in order for hypovolemic shock to occur the pt would need to lose _______ of their blood volume 15% If a pt has a blood volume of 5L and loses 2L, what is the percentage amount of volume loss this pt has experienced? 40% based on this amount of fluid loss, the pt would be in class III (stage 3 of hypovolemic shock) class III: volume loss is 30-40% or 1,500-2,000 mL in an adult a pt who is experiencing hypovolemic shock has decreased CO, which contributes to ineffective tissue perfusion. The decrease in CO occurs d/t? a decrease in cardiac preload bc there is a major depletion of volume in the intravascular system, there will be a decrease in the amount of venous return to the heart - this will lead to a DECREASE in preload A pt has a 10% loss of their blood volume. Select all the s/s this pt may present with a. cool, clammy skin b. BP WNL c. anxiety d. cap refill 2 seconds e. UO 30mL/hr f. mild tachycardia b, d, e the body can compensate for a volume loss of 15% to maintain CO. Pt will be asymptomatic until blood loss is 15% During what stage (or class) of hypovolemic shock does the SNS attempt to maintain CO? stage II CO is falling even more d/t volume loss. This is when the pt has lost 15-30% of volume. One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply: a. Temp 104.8 F b. HR 40 bpm c. HR 140 bpm d. anxiety, restlessness e. UO 15mL/hr f. BP 70/56 g. pale, cool skin h. weak peripheral pulses i. BP 220/106 c, d, e, f, g, h s/s of hypovolemic: -tachycardia -hypotension -incr RR -cool, pale, clammy skin -anxiety -decr UO -weak peripheral pulses You're providing care to a patient who has experienced a 45% loss of their fluid volume and is experiencing hypovolemic shock. The patient has hemodynamic monitoring and fluid resuscitation is being attempted. Which finding indicates the patient is still in hypovolemic shock? low central venous pressure CVP is measurement of the pressure in the RA and superior vena cava. If fluid volume is low the pressure in this area will also be low A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient? modified Trendelenburg pt is supine w/their legs elevated at 45 degrees. This will help increase venous return to the heart, which will help increase CO A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to? establish 2 large-bore IV access sites major risk for hypovolemic shock d/t multiple long bone fractures and an internal abdominal injury. Fluids and blood products will need to be given to the pt along w/pain meds A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action? a. HR 115 b. dyspnea and crackles in lung fields c. anxious d. UO 35mL/hr b. dyspnea and crackles in lung fields when crystalloids are given there is a risk for fluid volume overload even thought the pt is hypovolemic You're providing an in-service to new nurse graduates on the fluid treatment for hypovolemic shock. You ask the participants to list the types of crystalloid solutions used in hypovolemic shock. LR NS select all the fluid types below that are considered colloids a. FFP b. albumin c. NS d. LR e. hetastarch f. platelets b, e C/D = crystalloids A/F = blood products A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to? a. rapidly infuse fluids b. warm fluids c. change tubing in between bags d. keep pt supine b. warm fluids prevent development of hypothermia The patient with hypovolemic shock is in need of clotting factors. Which type of fluid would best benefit this patient? FFP Cardiac output is very important for determining if a patient is in cardiogenic shock. What is a normal cardiac output in an adult? 4-8 L/min ________________ is the amount the ventricle stretches at the end of diastole. preload hence its the amount the ventricles stretches once its filled w/blood and right before the contraction of the ventricle.. so its the EDV Cardiac output is equal to the heart rate multiplied by the stroke volume. Treatment for cardiogenic shock includes medications that increase cardiac output. One of the factors that help determine cardiac output is stroke volume. What factors determine stroke volume? preload, afterload, contractility CO is determined by HR x SV SV = amount of blood pumped from LV/beat (50-100 mL) _____________ is the force the heart has to pump against to get blood out of the ventricle. afterload pressure the ventricle must pump against to squeeze blood out -the force the heart has to pump against to get blood out of the ventricle T/F: If a patient with cardiogenic shock is given a medication that will decrease cardiac afterload, it will decrease stroke volume. FALSE if a pt w/cardiogenic shock is given a med that will decr cardiac afterload, it will INCREASE stroke volume if we DECREASE the resistance the heart must pump against, it will increase how much blood it will pump out, hence increase SV Which patient below is at MOST risk for developing cardiogenic shock? a. 52 yo male experiencing severe allergic reaction from shellfish b. 25 yo female who experienced an upper thoracic SCI c. 72 yo male post op liver transplant d. 49 yo female experiencing acute MI d. 49 yo female experiencing acute MI MI is the main cause of cardiogenic shock happens bc a coronary artery has become blocked - causing a pump failure You're caring for a patient with cardiogenic shock. Which finding below suggests the patient's condition is worsening? Select all that apply: a. BP 95/68 b. UO 20 mL/hr c. CI 3.2 L/min/m2 d. PAWP 30 mmHg b, d normal UO: 30mL/hr (30 indicates kidneys not being perfused) normal PAWP: 4-12 ( 18 indicates cardiogenic shock - which means there is back flow of blood into the heart and lungs) A patient with cardiogenic shock has a blood pressure of 70/38. In addition, the patient is experiencing dyspnea with a respiratory rate of 32 breaths per minute and has an oxygen saturation of 82% on room air. On auscultation, you note crackles throughout the lung fields. You notify the physician. What order below would you ask for an order clarification? a. Dopamine IV stat b. NS IV bolus stat c. Furosemide IV stat d. place pt on CPAP b. NS IV bolus stat NS: would add more fluid to the lungs and further congest the fluids Dopamine: can help provide a positive inotropic effect (incr contractility of the heart which will incr SV and CO) Furosemide: helps remove extra fluid volume from the lungs CPAP: will help with oxygenation You're assessing your patient with cardiogenic shock, what signs and symptoms do you expect to find in this condition? Select all that apply: a. warm, flushed skin b. prolonged capillary refill c. UO 30mL/hr d. systolic BP 90 mmHg e. crackles in lung fields f. dyspnea g. decreased BUN and creatinine h. strong peripheral pulses i. chest pain b, d, e, f, i s/s will be r/t LOW cardiac output and decreased perfusion to organs/tissues A patient is receiving treatment for an acute myocardial infarction. The nurse is closely monitoring the patient for signs and symptoms associated with cardiogenic shock. Which value below is associated with cardiogenic shock? a. CI 1.5 L/min/m2 b. Pulmonary capillary wedge pressure (PCWP) 10 mmHg c. CVP 4mmHg d. Troponin 0.01 a. cardiac index 1.5 a normal cardiac index should be 2.5-4L/min/m2 Any number 2.2 can be associated with cardiogenic shock A patient who has cardiogenic shock is experiencing labored breathing and low oxygen levels. A STAT chest x-ray is ordered. The x-ray results show pulmonary edema. The physician orders Furosemide IV. What finding would require immediate nursing action? a. BP 98/54 b. UO 45mL/hr c. Potassium 1.8 mEq/L d. HR 110 c. potassium 1.8 furosemide is a dietetic which wastes potassium. The nurse would want to ensure the potassium level is normal before administering IV Furosemide They physician orders a Dobutamine IV drip on a patient in cardiogenic shock. After starting the IV drip, the nurse would make it priority to monitor for? worsening hypotension dobutamine increases contractility and CO, BUT causes vasodilation d/t the way it acts on receptors and this may make hypotension WORSE Which medications below are used in cardiogenic shock that provide a positive inotropic effect on the heart? dobutamine dopamine these are vasopressors that have a POSITIVE inotropic effect on the heart. These meds increase the strength of the heart's contractions, which increases SV A patient with cardiogenic shock has an intra-aortic balloon pump. As the nurse you know that during ________ the balloon deflates and during _____ the balloon inflates in a section of the aorta. systole, diastole You're precepting a new nurse. You ask the new nurse to list the purpose of why a patient with cardiogenic shock may benefit from an intra-aortic balloon pump. What are some of the indications the new nurse can list for the purpose of an intra-aortic balloon pump? helps increase blood flow to the coronary arteries the balloon pump will help increase CO what are the four stages of shock Initial Compensatory Progressive Refractory During the __________ stage of shock, the signs and symptoms are very subtle. However, cells are experiencing _________ due to the lack of tissue perfusion, which causes the cells to switch from ___________ metabolism to _________ metabolism. initial; hypoxia; aerobic; anaerobic You're caring for a patient who is experiencing shock. Which lab result below demonstrates that the patient's cells are using anaerobic metabolism? a. ammonia 18 u/dL b. potassium 4.5 mEq/L c. serum lactate 9 mmol/L d. bicarbonate 23 mEq/L c. serum lactate 9 a pt who is in shock will experience anaerobic metabolism bc the cells can no longer use oxygen for energy d/t the loss of tissue perfusion normal lactate: 1mmol/L lactic acidosis: 4 mmol/L During what stage of shock does the body attempt to utilize the hormonal, neural, and biochemical responses of the body? compensatory During shock, when a patient experiences a drop in cardiac output, the body tries to compensate by stimulating the sympathetic nervous system, which causes the release of _________ and ________. This will lead to? norepinephrine and epinephrine; vasoconstriction by causing constriction of the vessels, it will temporarily increase CO by increase the BP and HR, which will turn increase perfusion to cells When the body is attempting to compensate for shock the adrenal cortex will release aldosterone due to the presence of angiotensin II. Select all the effects aldosterone will have on the body in attempt to increase cardiac output and maintain tissue perfusion: increase blood volume causes the kidneys to keep sodium and water -aldosterone functions to cause the kidneys to KEEP sodium and water, which will INCREASE the blood volume During what stage of shock is the body unable to compensate for tissue perfusion and the body's cell start to experience hypoxic injury that result in __________capillary permeability? progressive; increased TRUE or FALSE: All types of shock during the compensatory (early) stage will cause a patient to experience cold and clammy (moist or sweaty) skin FALSE pts who have septic shock will actually experience warm and flushed skin during the early (compensatory stage) bc of the vasodilation occurring w/this type of shock Which stage of shock is irreversible and unmanageable? refractory Based on this scenario, what stage of shock is this patient most likely experiencing: A 74-year-old patient is extremely confused and does not respond to commands or stimulation. The patient respiratory rate is 28 and labored, oxygen saturation 86%, heart rate 120, blood pressure 70/40, mean arterial pressure is 50 mmHg, and temperature is 97 'F. The patient's heart rhythm is atrial fibrillation. The patient's urinary output is 5 mL/hr. The patient's labs: blood pH 7.15, serum lactate 15 mmol/L, BUN 55 mg/dL, Creatinine 6 mg/dL. In addition, the patient is now starting to have slight oozing of blood around puncture sites. progressive the pt is experiencing major s/s of shock. In addition the body is no longer compensating bc the BP is very low along w/the MAP a pt has developed bradycardia and symptoms of shock. Which medication would the nurse most likely administer to correct this situation atropine treatment of severe bradycardia, and is one of the first drugs admin for very low heart rate during advanced cardiac life support A 28 yo pt is brought to the ED after a MVC and has suffered a fractured pelvis. The pt is demonstrating s/s of hemorrhagic shock as a result of his injuries. Which type of fluid would be most appropriate to administer initially during the resuscitation period LRs restores the intravascular volume that was lost d/t hemorrhage. It's a crystalloid solution that is recommended as one of the first types of fluids to admin in the case of hemorrhagic shock a nurse is assessing a pt. Which of the following s/s would indicate the pt is in shock? SATA a. blue nail beds b. rapid pulse rate c. shallow respirations d. yellowing of sclera e. wheezy breath sounds a, b, c some s/s include: incr RR, shallow depth of respirations, incr pulse rate, cyanosis, decrease of PaO2 and PaCO2 A client who was diagnosed with heart failure has developed cardiogenic shock as a complication of the condition and needs an intra-aortic balloon pump placed. Which of the following statements accurately describes an intra-aortic balloon? the balloon is regularly inflated and deflated to support the pumping action of the heart -increases ejection fraction, CO and coronary perfusion Which best describes the difference between septic shock and multiple organ dysfunction syndrome (MODS)? septic shock is caused by infection that results in hypoperfusion, while MODS involves hypoperfusion as well as other body system abnormalities A new nurse is having a difficult time knowing which client should be seen first because they all seem important. The nurse preceptor helps and explains that the client with which of the following should be seen first? a. hypotension, tachycardia, lethargy b. febrile, tachycardia, vomiting c. abdominal pain, hypertensive and constipated d. dizziness w/normal vital signs a. hypotension, tachycardia and lethargy hypotensive pt w/tachycardia is concerning for hypovolemia or shunting especially w/lethargy Which of the following conditions put a client at risk for cardiogenic shock? Select all that apply. a. cardiac tamponade b. hypotension c. damaged heart valves d. PE e. DVT a, c, d A nurse is caring for a client who is being treated for acute myocardial infarction. The nurse knows that some clients with acute MI go on to develop cardiogenic shock, which can be fatal. Based on the nurse's understanding of this condition, the nurse knows to look for which of the following signs of cardiogenic shock? oliguria and poor peripheral pulses cardiogenic shock develops when the body cant get blood to the tissues and organs bc of a problem w/the heart. S/s are assoc w/decr tissue perfusion and incl. low BP, poor peripheral pulses, tachycardia, tachypnea, pulmonary congestion, disorientation, and confusion, cool extremities, decr UO The priority nursing intervention for septic shock is which of the following? provide IV antibiotics MAKE SURE blood cultures are drawn prior to antibiotic administration some friends spent the day outside in the Dominica. At the end of the day, one of your friends complains of a sunburn. His back is very red, swollen, warm, and painful to touch. Which of the following is most likely to have caused the swelling? a. histamine b. kinin c. leukotrienes d. eosinophils a. histamine stimulates our nerve endings approximately 5 mins after being bit by a mosquito a 26 yo medical student observes the lesion at the right. What causes the erythema? vasodilation a pt with an inflammatory has high eosinophil count. The nurse recognizes that this finding indicates that tissue damage has been caused by an allergen-antibody reaction a pt arrives in the ED with a swollen ankle after an injury occurred while playing soccer. which action by the nurse is appropriate? a. remove pt shoe and sock b. elevate the ankle above heart level c. apply warm moist pack to the ankle d. assess the ankles ROM b. elevate ankle above heart level RICE: Rest, Ice, Compress, Elevate A 45 year old female patient has superficial partial thickness burns on the posterior head and neck, front of the left arm, front and back of the right arm, posterior trunk, front and back of the left leg, and back of right leg. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? 22,932 mL Formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. Pt's weight 91 kg. BSA percentage: 63%... posterior head and neck (4.5%), front of the left arm (4.5%), front and back of the right arm (9%), posterior trunk (18%), front and back of the left leg (18%), back of right leg (9%) equals: 63%......4 x 63 x 91 = 22,932 mL A 30 year old female patient has deep partial thickness burns on the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. The patient weighs 150 lbs. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? 10,064 mL Formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. Pt's weight 150 lbs....convert to kg....150 divided by 2.2 = 68 kg. BSA percentage: 37%...Back of right arm (4.5%), posterior trunk (18%), front of left leg (9%), anterior head and neck (4.5%) and perineum (1%) which equals 37%......4 x 37 x 68 = 10,064 mL A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? 921 mL/hr First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 63 kg. BSA percentage: 58.5%...Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742 mL......Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL......Hourly Rate: 7371 divide by 8 equals 921 mL/hr A 59 year old male patient has full thickness burns on both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. The patient weighs 186 lbs. Use the Parkland Burn Formula: You've already infused fluids during the first 8 hours. Now what will you set the flow rate during the next 16 hours (mL/hr) based on the total you calculated? 861 mL/hr First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 186 lbs...need to convert to kg: 186 divided by 2.2 = 85 kg. BSA percentage: 81%...Both of the legs on the back (18%), front and back of the trunk (36%), both arms on the front and back (18%), front and back of the head and neck (9%) which equals 81%.......4 x 81 x 85 = 27,540 mL. You've already infused half of the solution during the first 8 hours...so 13,770 mL is left and it needs to be infused over 16 hours. Hourly rate: 13,770 mL divided by 16 hours equals 861 mL/hr A 29 year old male patient has superficial partial thickness burns on the anterior right arm, posterior left leg, and anterior head and neck. The patient weighs 78 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? 5,616 mL. Formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. Pt's weight 78 kg. BSA percentage: 18%...Anterior right arm (4.5%), posterior left leg (9%), and anterior head and neck (4.5%) which equals 18%.....4 x 18 x 78 = 5,616 mL A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned? 37% Back of right arm (4.5%), posterior trunk (18%), front of left leg (9%), anterior head and neck (4.5%) and perineum (1%) which equals 37%. A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage that is burned? 58.5% Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. A 35 year old male patient has full thickness burns to the anterior and posterior head and neck, front of left leg, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned? 19% Anterior and posterior head and neck (9%), front of left leg (9%), perineum (1%) which equals 19%. A 66 year old female patient has deep partial-thickness burns to both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned? 81% Both of the legs on the back (18%), front and back of the trunk (36%), both arms on the front and back (18%), front and back of the head and neck (9%) which equals 81%. A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? 63% Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%. A 35 year old male patient has superficial partial-thickness burns to the anterior right arm, posterior left leg, and anterior head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned? 18% The nurse is caring for a patient with an arterial monitoring system. The nurse asses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intra-arterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? Select one: a. Frequent oropharyngeal suctioning b. Side to side position changes c. Range-of-motion to extremities d. Frequent neurological assessments d. Frequent neurological assessments The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 40% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? Select one: a. 14000 ml b. 2800 ml c. 7000 ml d. 11200 ml a. 14000 ml For patients with major burns, when should you start enteral feedings? Select one: a. A few hours after the injury has occurred b. Not until bowel sounds have returned c. After the emergent phase of the injury d. 2 to 3 days after the injury c. After the emergent phase of the injury After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? Select one: a. Patient with meningitis complaining of photophobia b. A patient with bacterial meningitis on droplet precautions c. Mechanically ventilated patient with a GCS of 6 d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F The charge nurse assigns patients based on their acuity and the level of experience of the critical care nurses on duty. This is an example of implementation of: Select one: a. Healthy work environment b. National patient safety goals c. SBAR communication d. Synergy model d. Synergy model While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? Select one: a. Insert bilateral cotton nasal packing. b. Have the patient blow the nose until clear. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears. c. Place a nasal drip pad under the nose. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? Select one: a. stimulate the patient hourly. b. Notify the provider immediately. c. Elevate the head of the bed. d. Continue to monitor the patient. b. Notify the provider immediately. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient's hands clench and pull into the chest. What is the best interpretation by the nurse? Select one: a. The patient is exhibiting purposeful movement. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting extension posturing. d. The patient is exhibiting decorticate posturing. d. The patient is exhibiting decorticate posturing. (9) Which of the following would be seen in a patient with myxedema coma? Select one: a. Decreased reflexes b. Hyperthermia c. Tachycardia d. Hyperventilation a. Decreased reflexes A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient? Select one: a. Idioventricular rhythm b. Sinus bradycardia c. Junctional rhythm d. Atrial fibrillation d. Atrial fibrillation A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? Select one: a. Chloride b. Sodium c. Potassium d. Calcium c. Potassium diabetic ketoacidosis, the laboratory results are similar to those of hyperosmolar hyperglycemic syndrome, with three major exceptions. What differences would you expect to see in patients with diabetic ketoacidosis? Select one: a. Lower serum glucose, lower osmolality, and no ketosis b. Higher serum glucose, higher osmolality, and no ketosis c. Lower serum glucose, lower osmolality, and higher ketosis d. Higher serum glucose, higher osmolality, and higher ketosis b. Higher serum glucose, higher osmolality, and no ketosis A patient presents to the emergency department with the following clinical signs: Pulse: 132 beats/min, Blood pressure: 88/50 mm Hg, Respiratory rate: 32 breaths/min, Blood sugar of 60, fatigue, dizziness and darkening of skin. These signs are consistent with which disorder? Select one: a. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) b. Thyroid Storm c. Myxedema coma d. Adrenal Crisis b. Thyroid Storm Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? Select one: a. An 18-year-old college student with type 2 diabetes who was diagnosed with the flu b. An 83-year-old, long-term care resident with type 1 diabetes and new onset Alzheimer's disease. c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections d. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning b. An 83-year-old, long-term care resident with type 1 diabetes and new onset Alzheimer's disease. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? Select one: a. Increase supplemental oxygen delivery. b. Monitor the patient's airway patency. c. Elevate the head of the patient's bed. d. Support bony prominences with padding. b. Monitor the patient's airway patency. Which of the following statements is true about the medical management of diabetic ketoacidosis? Select all that apply Select one or more: a. Sodium bicarbonate is used to correct severe acidosis. b. Blood glucose levels are used to guide insulin administration. c. The degree of acidosis is assessed through continuous pulse oximetry. d. Volume replacement and insulin infusion often correct the acidosis. d. Volume replacement and insulin infusion often correct the acidosis. Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? Select one: a. Serum sodium 152 mEq/L b. Urinary sodium 22 mEq/L c. Serum potassium 5.8 mEq/L d. Fasting blood glucose 156 mg/dL b. Urinary sodium 22 mEq/L college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? Select all that apply: Select one or more: a. HCO3—: 10 mEq/L b. Blood glucose: 524 mg/dL c. pH: 7.40 d. Blood glucose: 43 mg/dL a. HCO3—: 10 mEq/L b. Blood glucose: 524 mg/dL d. Blood glucose: 43 mg/dL An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual's priority action? Select one: a. Drink additional water to prevent dehydration b. Eat an apple c. Take another dose of the glipizide d. Go to the first-aid station to have glucose checked b. Eat an apple An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis? Select one: a. Elevated thyroid-stimulating hormone b. Elevated cortisol levels c. Elevated T3 and T4 d. Elevated adrenocorticotropic hormone a. Elevated thyroid-stimulating hormone The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following? Select one: a. Infection b. Diabetes Insipidus c. Volume overload d. Congestive heart failure b. Diabetes Insipidus Which of the following interventions is a strategy to prevent fat embolism syndrome? Select one: a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with low-molecular weight heparin. d. Stabilize extremity fractures early. d. Stabilize extremity fractures early. A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? Select one: a. Blood pressure 82/60 mm Hg, heart rate 122 beats/min, respiratory rate 28 breaths/min b. Responsive only to painful stimuli c. Irregular heart rate and rhythm d. Crackles (rales) on auscultation of bilateral lung fields d. Crackles (rales) on auscultation of bilateral lung fields Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? Select all that apply Select one or more: a. Only fully crossmatched blood products are administered b. Lactated Ringer's is recommended for rapid crystalloid infusion. c. IV fluids may need to be warmed to prevent hypothermia. d. Massive transfusions should be avoided to improve patient outcomes. c. IV fluids may need to be warmed to prevent hypothermia. d. Massive transfusions should be avoided to improve patient outcomes. Which of the following statements about mass casualty triage during a disaster is true? Select one: a. Disaster victims with the greatest chances for survival receive priority for treatment. b. Once interventions have been initiated, health care providers cannot stop the treatment of disaster victims. c. Color-coded systems in which green indicates the patient of greatest need are used during disasters. d. Priority treatments and interventions focus primarily on young victims. a. Disaster victims with the greatest chances for survival receive priority for treatment. A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to Select one: a. Have the nurse assist with transport of patients to procedural areas. b. Thank the nurse but inform her to return to her department as her skill set is not a good match for patients' needs. c. Assign the nurse administrative duties, such as obtaining patient demographic information. d. Assign the nurse to a triage room with another nurse from the emergency department. c. Assign the nurse administrative duties, such as obtaining patient demographic information. An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? Select one: a. Level IV b. Level II c. Level III d. Level 1 d. Level 1 Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture? Select one: a. Placement of an oral airway b. Insertion of a nasotracheal tube c. Insertion of an indwelling urinary catheter d. Endotracheal intubation b. Insertion of a nasotracheal tube The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? Select all that apply Select one or more: a. Make frequent neurological assessments. b. Maintain CO2 level at 35-45 mm Hg. c. Prepare for thrombolytic administration. d. Maintain MAP greater than 130 mm Hg. d. Maintain MAP greater than 130 mm Hg. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. The blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 90 mm Hg. What is the cerebral perfusion pressure (CPP)? Select one: a. 90 mm Hg b. 72 mm Hg c. 126 mm Hg d. 54 mm Hg a. 90 mm Hg The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? Select one: a. Remove cervical collar upon arrival to the ED. b. Prepare for immediate endotracheal intubation. c. Keep the neck in the hyperextended position. d. Maintain proper head and neck alignment. d. Maintain proper head and neck alignment. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 55 mm Hg. What is the best interpretation by the nurse? Select one: a. ICP is high; CPP is low. b. Both pressures are low. c. Both pressures are high. d. ICP is high; CPP is normal. a. ICP is high; CPP is low. The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. An IV has been established and the patient has been given lorazepam, but the seizures continue. What is the next nursing priority? Select one: a. Obtain stat portable chest x-ray. b. Administer phenytoin. c. Administer 2nd lorazepam dose. d. Obtain stat serum electrolytes. b. Administer phenytoin. While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? Select one: a. Maintain neutral head alignment and avoid extreme hip flexion. b. Ensure adequate periods of rest between nursing interventions. c. Reduce ambient room temperature and administer antipyretics. d. Insert an oral airway and monitor respiratory rate and depth. b. Ensure adequate periods of rest between nursing interventions. The physician has ordered Dopamine to be administered @ a rate of 5 mcg/kg/min. The patient weighs 145 pounds and the drug is sent to the unit as Dopamine 400 mg in 250 mL D5W. The nurse will set the infusion pump @ ________mL/hr *Round to the nearest mL at the end of the equation 50mL/hr A patient has been admitted to the ICU for alcohol withdrawl and is ordered lorazepam 10 mg/hr. The pharmacy has sent lorazepam 120 mg in 600 mL of D5W. The nurse will infuse the medication on the infusion pump @ the rate of _______ mL/hr 2.05mL/hr The patient has hypokalemia and is to receive an IV infusion of potassium chloride. The physician orders the KCl to infuse at a rate of 2 mEq/hr. The pharmacy sends KCL 40mEq/L in D5W. The nurse will set the infusion pump @ ________ mL/hr 50mL/hr The physician has ordered nitroglycerin for a patient with chest pain at a rate of 10 mcg/min. The pharmacy provides Nitroglycerin 25 mg in 250 mL of D5W. The nurse will set the infusion pump @ a rate of _______ mL/hr. 0.1mL/hr During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent Select one: a. Multisystem organ dysfunction. b. Wound infection c. Disseminated intravascular coagulation. d. Septic shock. a. Multisystem organ dysfunction. The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient smells of alcohol and begins to vomit in the ED. Which of the following interventions is most appropriate? Select one: a. Prepare to suction the oropharynx while maintaining cervical spine immobilization. b. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content. c. Insert an oral airway to prevent aspiration and to protect the airway. d. Offer the patient an emesis basin so that you can measure the amount of emesis. a. Prepare to suction the oropharynx while maintaining cervical spine immobilization. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED Select one: a. Involves turning the patient from side to side to get a look at his back. b. Includes a cervical spine x-ray study to determine the presence of a fracture. c. Is done quickly in the first few minutes to get a baseline assessment and establish priorities. d. Is a methodical head-to-toe assessment identifying injuries and treatment priorities. c. Is done quickly in the first few minutes to get a baseline assessment and establish priorities. The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? Select one: a. Infection b. Central nervous system deficits c. Contractures d. Stress ulcers b. Central nervous system deficits A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters over the arms, chest, and neck; and red, painful oral mucous membranes. The patient should be further evaluated for which possible non-burn-injured skin disorder? Select one: a. Necrotizing soft tissue infection b. Graft-versus-host disease c. Staphylococcal scalded skin syndrome d. Toxic epidermal necrolysis d. Toxic epidermal necrolysis When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? Select one: a. Carbon monoxide poisoning always occurs when soot is visible. b. The patient will have a copious amount of mucus that will need to be suctioned. c. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways. d. Inhalation injury above the glottis may cause significant edema that obstructs the airway. d. Inhalation injury above the glottis may cause significant edema that obstructs the airway. In patients with extensive burns, edema occurs in both burned and unburned areas because of Select one: a. Catecholamine-induced vasoconstriction. b. Loss of integument barrier. c. Increased capillary permeability. d. Decreased glomerular filtration. c. Increased capillary permeability. The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to intravenous administration because Select one: a. Intramuscular injections cause additional skin disruption. b. Tissue edema may interfere with drug absorption of injectable routes. c. Hypermetabolism limits effectiveness of medications administered intramuscularly. d. Burn pain is so severe it requires relief by the fastest route available. b. Tissue edema may interfere with drug absorption of injectable routes. The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is Select one: a. Blood urea nitrogen. b. Daily weight c. Hourly intake and urine output d. Serum potassium c. Hourly intake and urine output An autograft is used to optimally treat a partial- or full-thickness wound that Select all that apply Select one or more: a. Is infected. b. Involves a joint. c. Requires less than 2 weeks for healing. d. Involves the face, hands, or feet. b. Involves a joint. c. Requires less than 2 weeks for healing. d. Involves the face, hands, or feet. The nurse is caring for a patient who has circumferential full-thickness burns of his forearm. A priority in the plan of care is Select one: a. To keep the extremity in a dependent position. b. To prepare for an escharotomy as a prophylactic measure. c. Active or passive range-of-motion exercises every hour. d. To splint the forearm. c. Active or passive range-of-motion exercises every hour. Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for Select one: a. Acute respiratory distress syndrome. b. Acute kidney injury. c. Infection d. Stress ulcers c. Infection A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Bas