MED SURG TEST BANK

MED SURG TEST BANK 1. A Nurse is panning care for a client who has prerenal acute kidney injury (AKI) Following abdominal aortic aneurysm repair. Urinary output is 60mL in the past 2hr and blood pressure is 92/58mm Hg. The nurse should expect which of the following interventions? Prepare to administer a challenge 2. A Nurse is assessing a client who has prerenal acute kidney injury (AKI) which of the following findings should the nurse expect? Select all that apply Elevated creatinine/ reduced urine output 3. In providing an educational in-service to the nursing staff about peritoneal dialysis, which information does the nurse include in this presentation? The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis. 4. Which statement by the family member of a client who has a Sengstaken- Blakemore tube placed to threat complications of liver disease indicates understanding of this treatment modality? The tube provides compression to stop esophageal bleeding 5. A client with chronic kidney disease is experiencing manifestations of anemia. Based on this date, which statement does the nurse anticipate for this client? Administer erythropoietin (epoetin) injections 6. The nurse is assessing a client in the ER with the following signs and symptoms; painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the umbilicus. The RN recognizes this as which sign? Cullen’s sign 7. The nurse is caring for a client receiving hourly peritoneal dialysis exchanges. During a one-hour exchange, the nurse infuses 2,000mL of dialysate and 1,900 mL of outflow is returned. During the exchange, the client drinks 8oz of apple juice, 2 cups of water and voids 150mL of urine. Calculate and record the client’s intake in millimeters and use numerical values only. 820 8. On which scientific rationale should a nurse base the response when a client asks, what does an elevated PSA test mean? An elevated PSA can result from several different causes 9. A client had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. The staff nurse notes that the urinary drainage is bright red and thick with clots. What is the nurse’s best action? Increase the rate of the bladder irrigation 10. A client with cholecystitis is placed on a low-fat, high-protein diet. Which nutrient should the nurse teach the client to include in this diet? Skim Milk 11. Which assessment data indicate to the nurse that the client may be experiencing decreased clotting factors as a complication of cirrhosis? Epistaxis 12. Discharge planning for a client with chronic pancreatitis includes dietary teaching. Which statement indicates to the nurse that the client needs more teaching? I can eat foods high in fat now that acute stage is over 13. A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? Assess level of consciousness 14. Which of the following findings should a nurse expect in a client with end-stage kidney disease? Select all that apply Anuria/ Marked azotemia/ crackles in the lungs/ proteinuria 15. In administering lactulose to the client with hepatic encephalopathy, the nurse correlates effectiveness of this medication to which mechanism of action? Decrease production of ammonia 16. A client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. The client returns from surgery with a T-tube connected to a drainage bag. What does the nurse conclude in the purpose of the T-tube? Permit drainage of bile 17. A client has an IV of D5W 250mL to which 100mg of morphine is added. The healthcare provider prescribes 14mg of morphine per hour for end of life palliative treatment of a client with liver failure. At how many mL per hour should the nurse set the infusion pump? Round to the nearest whole number and use numerical values only. 35 18. The nurse is planning education for an adolescent client recently diagnosed with hepatitis. The client moved back to the parent’s home. Which recommendation to the parents will best prevent them from acquiring hepatitis B (HBV)? Obtaining postexposure prophylaxis 19. The RN caring for a client with acute pancreatitis receives the following orders. “Administer 100mL/kg of body weight over 24hrs” the client weighs 80kg. What is the hourly rate the RN should place in the infusion pump. (Round to the nearest whole number and use numerical values only) 333 20. The 75-year-old client has undergone an open cholecystectomy for cholelithiasis 2 days ago and has a t-tube drain in place. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Take and record the client’s vital signs/ empty the client’s foley catheter bag at the end of the shift/ assist the client to ambulate in the hallway three to four times a day. 21. Which assessment data collected by the nurse after a liver biopsy requires the nurse to immediately notify the healthcare provider? The client’s blood pressure is 80/50mm Hg. 22. A nurse is monitoring a client post kidney biopsy for postoperative complications. Which of the following complications should the nurse identify as causing the greatest risk to the client? Hemorrhage 23. Which statement made by the client diagnosed with benign prostatic hyperplasia (BPH) indicates the need for further teaching about this disease process? An elevated PSA level indicates that I have prostate cancer 24. The nurse is providing information about hepatitis to a high school health occupations class. The students all volunteer examples of how hepatitis is transmitted. Which statement by of the students indicates the need for further teaching about hepatitis transmission? Mosquito or tick bite 25. Which of the following is the most appropriate therapeutic diet for a client diagnosed with acute renal failure? A high-carbohydrate and protein-restricted diet. 26. A client is to receive 2000mL of intravenous IV fluid in 12 hrs. At what rate should the nurse set the infusion pump? Round to the nearest whole #. 167 27. While administering peritoneal dialysis to a client with acute kidney injury the nurse notes the presence of cloudy dialysis return. After notifying the healthcare provider the nurse anticipates which order? Culture the dialysate return 28. A client is to receive an intravenous (IV) antibiotic in 50mL of 0.9% sodium chloride to be administered over 20min. at what rate should the nurse set the infusion pump? 150 29. Which nursing task is most appropriate for the RN to delegate to the unlicensed assistive personnel (UAP)? Assist the client with pruritus to the bathroom for a shower and a.m. care 30. Which statement by the client diagnosed with chronic pancreatitis indicate understanding of this disease process? I will avoid coffee and caffeine 31. Which client laboratory data should the nurse report to the HCP immediately? The elevated gamma glutamyl transferase report on a client with hepatitis 32. The nurse correlates which diagnostic results to the client diagnosed with advanced cirrhosis? Serum albumin 3.0mg/dL/ serum magnesium 1.2mg/dL/ serum sodium 130mEq/L 33. What will the nurse do to assess a client’s response to ongoing serum albumin therapy for cirrhosis of the liver? Obtain the client’s weight at least once every day 34. The client is one (1) day postoperative TURP. Which task would be appropriate for the nurse to delegate the UAP? Elevate the scrotum on a towel roll for support 35. The nurse correlates the metabolic alkalosis in the client diagnosed with hepatic encephalopathy to which potential causes? SATA Diarrhea/ diuretic therapy/ vomiting 36. A client’s potassium level is confirmed at 6.2 mmol/L. which of the following emergency intervention should the nurse be prepared to initiate? Start cardiopulmonary resuscitation 37. The client is diagnosed with liver failure is experiencing pruritus secondary to severe jaundice and is scratching the upper extremities. Which intervention should the nurse implement first? Place mittens on both hands of the client 38. The LPN tells the nurse the client is diagnosed with liver failure is getting more confused. Which intervention should the nurse implement first? Assess the client’s neurological status 39. The nurse monitors for which electrocardiogram change as the first indication of hyperkalemia in the client with acute kidney disease? Tall T waves 40. In administering an anticholinergic medication to a client diagnosed with benign prostatic hypertrophy, the nurse correlates the mechanism of action of this medication to which physiological response? Relaxes the smooth muscle of the prostate 41. A client is at high risk for developing ascites because of cirrhosis of the liver. How should the nurse assess for the presence of ascites? Percuss the client’s abdomen and listen for dull sounds 42. A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider’s prescription includes nothing by mouth and total parenteral nutrition (TPN) the nurse explains that the TPN therapy provides? Will meet the client’s nutritional needs without causing the discomfort precipitating by eating 43. A client is admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek’s sign. Which deficiency does the nurse suspect the client has? Calcium 44. The nurse monitors for which clinical manifestations in the patient diagnosed with chronic pancreatitis? SATA Clay-colored stool/ diarrhea/ steatorrhea 45. Which information should the nurse include in the teaching of a client with chronic kidney disease who is to begin hemodialysis? Hemodialysis returns a balance to blood electrolytes 46. A client who has liver failure with ascites is scheduled for a paracentesis. Which of the following actions should the RN anticipate prior to the procedure? SATA. Instruct client to void/ elevate head of the bed/ measure abdominal girth/ verify informed consent 47. In reviewing the treatment plan for the client diagnosed with ascites, which prescription does the nurse question? A 3 g/day sodium diet 48. A client with a history of recurrent cholecystitis is scheduled for an abdominal cholecystectomy. What should the nurse specifically emphasize when planning preoperative teaching for this client? Coughing and deep breathing 49. The nurse is reviewing client laboratory date. Which of the following findings is expected for a client who has stage 4 chronic kidney disease? Glomerular filtration rate (GFR) 20L/min, creatinine 3.0mg/dL 50. Which of the following instructions should a nurse include in the teaching to be given to a client who is postoperative following a kidney transplant and is taking cyclosporine? Report fever and sore throat to your provider. Test 3 1. Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process? A thymectomy. 2. Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis? Ptosis and diplopia. 3. The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client’s significant others? Discuss ways to help prevent choking episodes. 4. Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? Progressive ascending paralysis of the lower extremities and numbness. 5. Which statement by the client supports the diagnosis of Guillain-Barré syndrome? “I had a really bad cold just a few weeks ago.” 6. The client diagnosed with Guillain-Barré syndrome asks the nurse, “Will I ever get back to normal? I am so tired of being sick.” Which statement is the best response by the nurse? “You should make a full recovery within a few months to a year.” 7. The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented? Monitor the client’s serum blood glucose levels frequently. 8. The client diagnosed with ALS asks the nurse, “I know this disease is going to kill me. What will happen to me in the end?” Which statement by the nurse would be most appropriate? “Most people with ALS die of respiratory failure.” 9. The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? 1. Elevate the head of the bed 30 degrees. 2. Administer oxygen via nasal cannula. 3. Assess the client’s lung sounds. 4. Obtain a pulse oximeter reading. 10. The client is to receive a 200-mL intravenous antibiotic over 30 minutes via an intravenous pump. At what rate should the nurse set the IV pump? 400ml 11. The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? Assist the client to prepare an advance directive. 12. The client is in the terminal stage of ALS. Which intervention should the nurse implement? Perform passive ROM every two (2) hours. 13. The health-care provider wants an SvO2 level on a patient with a pulmonary artery catheter. From where should this sample be taken? Distal lumen 14. The nurse is preparing to obtain a pulmonary artery wedge pressure (PAWP) on a patient. What action should be taken to ensure for the patient’s safety? Inflate the balloon 1.5 mL 15. The nurse wants to evaluate a patient’s right heart preload. Which approach should be used to obtain this measurement Measure the central venous pressure 16. The nurse suspects that a patient is experiencing a complication from a pulmonary artery catheter. What findings did the nurse use to make this clinical determination? Select all that apply. Bleeding Elevated body temperature Acute onset of shortness of breath Development of a cardiac dysrhythmia 17. The nurse is preparing to determine a patient’s left heart afterload. What measurements are needed to make this calculation? Select all that apply Cardiac output Mean arterial pressure Central venous pressure 1. The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? a. “You can see black smoke when carbon monoxide is in the air.” b. “If you are experiencing carbon monoxide poisoning, your skin will begin turning blue.” c. “The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire.” d. “It is important to have carbon monoxide detectors in your home, because this is an odorless gas.” 1. Which assessment finding does the nurse interpret as demonstrating a client’s fluid resuscitation adequacy? a. Decreased skin turgor b. Decreased pulse pressure c. Decreased core body temperature d. Decreased urine specific gravity 1. Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? (Select all that apply.) a. Place client in isolation. b. Encourage multiple visitors to support client. c. Ensure that no plants or flowers are in the client’s room. d. Teach family members not to bring fresh fruits and vegetables to the client. e. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another. 1. The nurse is encouraging range-of-motion exercises for the client, who states, “this hurts terribly; I don’t want to do this.” Identify the appropriate nursing response(s). (Select all that apply.) a. “You have to do the exercises to get well.” b. “Range-of-motion helps promote mobility.” c. “Just visualize a beach to get your mind off of the pain.” d. “Let me check when you were last given pain medication.” e. “What techniques for pain management have you used in the past that were helpful?” f. “The health care provider has ordered these exercises, and it is important that you do them as instructed.” 1. After a mass casualty event, the nurse is triaging clients in the field. Which client is correctly classified? a. 38-year-old with an open femur fracture: Black tag b. 42-year-old with multiple abrasions and contusions: Yellow tag c. 54-year-old with third-degree burns over 90% of the body: Green tag d. 61-year-old who is having difficulty breathing and wheezing: Red tag 1. A number of nurses are floated to the ED to care for clients affected by an earthquake. Which appropriate float nurse assignments will the ED charge nurse make? (Select all that apply.) a. GI laboratory nurse assigned to clients undergoing sedation b. Orthopedic nurse assigned to accompany clients to radiology c. Nursing administrator assigned to monitor loved ones in the waiting room d. Community health nurse assigned to care for clients with fractures e. Medical surgical nurse assigned to healthcare worker who is feeling overwhelmed 1. The experienced nurse is teaching a new nurse about hospital emergency plans and personal emergency preparedness. Which specific arrangements should the experienced nurse discuss? (Select all that apply.) a. Assembly of a “go bag” b. Plans for child and/or elder care c. Neighbor who is willing to care for dog d. Who will be called when the plan is activated e. How long an emergency is expected to last f. Where a nurse is expected to report if the emergency plan is activated g. Names, addresses, and telephone numbers to be used if a crisis occurs 1. In a disaster, which hospital department is responsible for the secondary triage of patients? 1. Medical unit 2. Operating suite 3. Radiology department 4. Emergency department 2. The nurse responds to a mass casualty event and implements Simple Triage and Rapid Treatment (START) to triage patients. Which patient does the nurse tag as green? 1. The patient who remains apneic after airway repositioning. 2. The patient who begins breathing after airway management is implemented. 3. The patient who is walking, has abrasions, and follows commands appropriately. 4. The breathing patient with a capillary refill of 3 seconds who cannot follow simple direction. 3. When conducting triage assessments using Simple Triage and Rapid Treatment (START), how long does the nurse assess a patient before moving to the next one? 1. 15 seconds or less 2. 30 seconds or less 3. 45 seconds or less 4. 60 seconds or less 4. The nurse is conducting triage under mass casualty conditions and assigns which tag to the patient who is experiencing hypovolemic shock as a result of a penetrating wound? 1. Red 2. Black 3. Green 4. Yellow 5. Which patient injury would receive a black tag by the triage nurse during a mass casualty incident? 1. Concussion 2. Ankle sprain 3. Open femur fracture 4. Full-thickness body burns 6. Based upon Simple Triage and Rapid Treatment (START), the nurse tags the patient with which injury as yellow during the triage process? 1. Ankle sprain 2. Hypovolemic shock 3. Open femur fracture 4. Massive head trauma 7. What is the priority intervention when treating patients during a mass casualty event using Simple Triage and Rapid Treatment (START)? 1. Assessing for a pulse 2. Administering oxygen 3. Preparing for endotracheal tube intubation 4. Applying direct pressure to control bleeding 8. What is the goal of triage? 1. Maximize number of survivors 2. Provide lifesaving measures 3. Determine level of care needed 4. Prioritize care needs of all victims 9. Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks? 1. Anthrax exposure 2. Multi-casualty incidents 3. Mass casualty incidents (MCI) 4. Weapons of mass destruction (WMD) 10. The nurse works in an emergency department (ED) in a city that experiences an earthquake prepares to care for patients with which type of injury? 1. Drowning 2. Electrocution 3. Crush injuries 4. Carbon monoxide poisoning 11. What is the priority in the preparedness of healthcare professionals in any type of disaster plan? 1. Identification of hazards 2. Cooperation with state authorities 3. Collaboration with local authorities 4. Implementation of federal mandates 12. The nurse is helping devise a training plan to familiarize healthcare providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees? 1. Drills 2. Tabletop exercises 3. Access to the policy 4. Computer simulations 13. During the implementation of a disaster plan, who is responsible for all aspects of the response? 1. Planning chief 2. Operations officer 3. Logistics section chief 4. Incident commander 14. During the implementation of a disaster plan that involves exposure to toxic substances, who is responsible for decontamination? 1. Safety/security officer 2. Operations chief 3. Logistics section chief 4. Incident commander 15. Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? 1. Local emergency management system 2. State emergency management system 3. Federal emergency management agency 4. Hospital-level emergency management system 16. What is the highest level of personal protective equipment (PPE) for respiratory protection? 1. Level A 2. Level B 3. Level C 4. Level D 17. The nurse dons which level of personal protective equipment (PPE) when needing only protection from nontoxic (nuisance) contamination? 1. Level A 2. Level B 3. Level C 4. Level D 18. The nurse dons which level of personal protective equipment (PPE) when assigned to care for a patient when the type of airborne exposure is known? 1. Level A 2. Level B 3. Level C 4. Level D 19. The nurse dons which level of personal protective equipment (PPE) when assigned to care for a patient when the type of airborne exposure is unknown? 1. Level A 2. Level B 3. Level C 4. Level D 20. The nurse dons which level of personal protective equipment (PPE) when assigned to care for a patient requiring the highest level of respiratory protection but less skin protection? 1. Level A 2. Level B 3. Level C 4. Level D 21. The nurse understands that which is an example of an internal threat that could lead to a “shelter in place” (SIP) order? 1. Infrastructure damage from an earthquake 2. Civil unrest 3. Chemical release 4. Terrorist threat 22. What is the most common example of an advanced warning event that might require a hospital evacuation? 1. Bomb threat 2. Earthquake 3. Hurricane 4. Tornado 23. Which organization requires hospitals to have disaster and evacuation plans in the event of an emergency? 1. American Hospital Association (AHA) 2. Hospital Regulatory Agency 3. Homeland Security 4. Federal Emergency Management Agency (FEMA) 24. The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year? 1. Two 2. Three 3. Four 4. Five 25. A green-tagged patient arrives at the emergency department after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this patient? 1. Implementing decontamination measures 2. Performing a head-to-toe physical examination 3. Placing a special bracelet with a disaster number 4. Taking a digital photo and placing it on the medical record 1. In preparing an educational presentation regarding potential injuries and medical issues during a blizzard, the nurse includes which injuries? Select all that apply. 1. Orthopedic issues 2. Acute myocardial infarction 3. Carbon monoxide poisoning 4. Animal attacks/bites 5. Abdominal trauma 2. The nurse provides care to patients who have been exposed to radiation. Which actions does the nurse implement to minimize personal exposure? Select all that apply. 1. Use hand sanitizer after patient contact. 2. Ensure that all personal vaccinations are current. 3. Wear a radiation badge to monitor exposure time. 4. Provide distance from the source if on site of the accident. 5. Wear appropriate personal protective equipment when providing patient care. 3. What are the three main goals of decontamination? Select all that apply. 1. Enlist as many hospital personnel as possible. 2. Restrict contaminated patients from entering the hospital. 3. Decontaminate patients as quickly as possible. 4. Protect the decontamination team. 5. Treat all patients who are contaminated in the emergency department. 4. Which events may require a hospital evacuation with no advanced warning? Select all that apply. 1. Explosions 2. Floods 3. Building Fires 4. Hurricanes 5. Tornadoes 5. What are the key elements to ensure the safety of all personnel participating in an emergency hospital drill? Select all that apply. 1. Use real equipment. 2. All drill communications begin and end with “This is a drill.” 3. Have strict start and stop times for the drill. 4. There must be a safety officer with the sole responsibility to monitor any unsafe situations. 5. Use strategies to make the situation realistic. 1. The nurse is preparing an educational tool to instruct community members on burn prevention. What does the nurse include as the most common injury in children younger than age 5? 1. Scald 2. Flame 3. Chemical 4. Carbon monoxide poisoning 2. A patient presents to the emergency room seeking treatment for radiation burns. What needs to be considered before providing care to this patient? 1. Pathway of flow through the body 2. Duration of contact with the agent 3. Type, dose, and length of exposure 4. Temperature to which the skin is heated 3. The nurse monitors for which assessment findings in the patient admitted with superficial partial-thickness burns over both anterior lower arms? 1. Dry with no blisters 2. Waxy appearance and cherry red color 3. Dry leathery appearance and pale or brown color 4. Open or closed blisters, mild edema, easily blanches 4. A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What is the nurse’s best response? 1. “More than 2 weeks.” 2. “Within 1 to 2 weeks.” 3. “Within 24 to 72 hours.” 4. “You will need skin grafts.” 5. A patient has full-thickness burns over 30% of total body surface area. Which intervention to address the patient’s comfort does the nurse question? 1. Elevate injured extremities. 2. Medicate for pain around the clock. 3. Apply medicated ointment to all areas. 4. Elevate the head of the bed 30 degrees. 6. A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient? 1. Increased zone of stasis 2. Increased zone of hyperemia 3. Increased zone of coagulation 4. Decreased zone of coagulation 7. A victim of a house fire is brought to the emergency department for burn treatment. The nurse correlates which assessment to an inhalation injury? 1. Coughing 2. Soot on the face 3. Singed facial hair 4. Heart rate 98 bpm 8. In caring for patient with 50% total body surface area burns, the nurse correlates which finding to resolution of burn shock? 1. Heart rate 112 bpm 2. Respirations 24 per minute 3. Blood pressure 90/60 mm Hg 4. Urine output 800 mL over 2 hours 9. The nurse is caring for a patient who sustained electrical burns. What is the rationale for monitoring this patient for compartment syndrome? 1. Potential for undiagnosed injuries 2. Injuries from being thrown bruise soft tissue 3. Electrical current alters integrity of blood vessels 4. Fluid seeps from intravascular spaces into the interstitium 10. The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient? 1. Chest x-ray 2. Bronchoscopy 3. Computed tomography (CT) scan of the head 4. 12-lead electrocardiogram 11. The nurse provides care to a patient who is in the emergency department (ED) with a burn injury. What is the priority action by the nurse during the emergent phase of care? 1. Providing pain medications 2. Placing an indwelling urinary catheter 3. Administering the prescribed high-flow 100% oxygen by mask 4. Inserting two large-bore intravenous catheters in preparation for fluid resuscitation 12. In providing care to a victim of a car fire who is confused, dizzy, and nauseated, the nurse recognizes the need for which diagnostic test to determine if this patient is experiencing carbon monoxide poisoning? 1. Arterial blood gas (ABG) 2. Bronchoscopy 3. Pulse oximeter 4. Carboxyhemoglobin level 13. The nurse is caring for a patient with 45% total body surface area thermal burns. The nurse monitors for which laboratory result? 1. Increased pH 2. Increased sodium 3. Increased potassium 4. Decreased hematocrit 14. The nurse provides care to a patient who sustained burns on 75% of the body. Which data requires the nurse to notify the healthcare provider? 1. Pain rating of 8 on a 1 to 10 point scale 2. Heart rate 90 bpm 3. Urine output 2 mL/kg per hour 4. Blood pressure 96/50 mm Hg 15. The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicate that additional fluid resuscitation is required? 1. Blood pH 7.39 2. Heart rate 112 bpm 3. Blood pressure 110/60 mm Hg 4. Central venous pressure 2 mm Hg 16. In providing care to a patient admitted with a suspected inhalation injury, what nursing action in the priority? 1. Administering intravenous lactated Ringer’s fluid 2. Turning in bed every 2 hours 3. Monitoring intake and output 4. Administering 100% humidified oxygen 17. A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment data does the nurse correlate to successful wound care treatment? 1. Gray wound bed 2. Separation of eschar 3. Development of eschar 4. Presence of purulent exudate 18. The nurse administers a large dose of the prescribed opioid analgesic in preparation for a dressing change for a patient with significant burn injury. What is the nurse’s priority in this situation? 1. Ensuring a bag and mask is at the bedside 2. Asking the patient, “Are you allergic to any medications?” 3. Documenting the level of pain before medication administration 4. Evaluating the patient’s level of pain after medication administration 19. In providing care to a patient with 70% total body surface area chemical burns, the nurse correlates which as most effective in meeting this patient’s nutritional needs? 1. Parenteral nutrition 2. Duodenal tube feedings 3. Nasogastric tube feedings 4. Six small high-calorie meals per day 20. A patient recovering from 25% total body surface area burns has a low-grade fever. What actions are the priority for the nurse to reduce this patient’s risk of developing an infection? 1. Following contact precautions 2. Implementing protective isolation 3. Using sterile technique for all dressing changes 4. Administering prophylactic antibiotics as prescribed 21. The nurse is evaluating the nutritional status of a patient recovering from 24% total body surface area burns. Which data indicate adequate nutritional status? 1. Urine output of 50 mL/hour 2. Serum protein level 7.1 g/dL 3. Serum albumin level 2.8 g/dL 4. +1 pitting edema of lower extremities 22. A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment? 1. Skin warm and moist 2. Pedal pulses present but faint 3. Scattered areas of scarring noted 4. Nonpitting edema of both ankles 1. The school nurse is preparing material for National Fire Prevention Week. What information should be added to the classroom posters? Select all that apply. 1. Never leave a burning candle unattended. 2. Set heating pads on “low” when sleeping. 3. Keep a flashlight and telephone near the bed. 4. Check smoke alarm batteries every 12 months. 5. Never use the oven as a method to warm the home. 2. In caring for a patient who sustained chemical burns, the nurse correlates which as potential causes of these injuries? Select all that apply. 1. Lime 2. Gasoline 3. Bleach 4. Fabric softener 5. Hydrofluoric acid 3. A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient if the blisters are broken? Select all that apply. 1. Apply bacitracin ointment. 2. Cover with a nonadherent bandage. 3. Apply mafenide acetate 10% cream. 4. Wash with antiseptic soap and warm water. 5. Apply collagenase and cover with roll gauze. 4. A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which complications does the nurse provide care to this patient? Select all that apply. 1. Hyperkalemia 2. Depression 3. Fluid volume deficit 4. Body image disorder 5. Post-traumatic stress disorder (PTSD) 1. An adult patient received burns over both upper and lower arms, both hands, anterior upper and lower legs, anterior chest, and the neck. Using the following as a guide, what is this patient’s total body surface percentage of area burned? 67 2. A patient weighing 187 lbs. has 38% total body surface area burns. Using the Advanced Burn Life Support resuscitation guidelines, how much fluid should this patient receive over the first 8 hours after the burn occurred? Record the answer as a whole number. 3,230 mL 3. The nurse provides care to an adult patient with burns over 36% of the body. The patient’s current weight is 110 lbs. (50 kg). Using the Advance Burn Life Support guidelines, what is the total volume the patient needs to receive in the first 24 hours after the burn? 3,600 mL 4. The nurse provides care to a 40-year-old patient with burns on 24% of the body. The patient’s current weight is 110 lbs. (50 kg). The patient received fluid resuscitation for 8 hours using the Advanced Burn Life Support (ABLS) guidelines. At what rate (mL/hour) does the nurse set the pump for the patient to receive the remaining fluid over the next 16 hours? Record as a number with no units of measurement. 75 1. Which is the critical factor among health-care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster? 1) Cooperation 2) Classification 3) Collaboration 4) Communication 2. A workplace violence prevention plan is often one component of a hospital disaster plan. Which unit assumes priority for implementation and evaluation of this component to the plan? 1) Medical unit 2) Surgical unit 3) Radiology department 4) Emergency department 3. Which is the priority in the preparedness of health-care professionals in any type of disaster plan? 1) Identification of hazards 2) Cooperation with state authorities 3) Collaboration with local authorities 4) Implementation of federal mandates 4. Which treatment for anthrax should be included in the biological agent portion of a disaster plan for terrorist attacks? 1) Antivirals 2) Antitoxins 3) Antibiotics 4) Vaccinations 5. Which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack? 1) Atropine 2) Dopamine 3) Epinephrine 4) Norepinephrine 6. Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)? 1) Covering the nose 2) Protecting the eyes 3) Decontaminating the skin 4) Administering prophylactic antibiotics 7. Which health-care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? 1) Fireman 2) Police officer 3) Critical care nurse 4) Unlicensed assistive personnel 8. Which situation does not cover nurses who respond to a mass casualty incident (MCI) for malpractice or negligent lawsuits under the Good Samaritan Act? 1) Terrorist act 2) Neighborhood fire 3) Roadside car accident 4) High school sporting event 9. The nurse is a first responder for a health-care organization for a mass casualty incident. Which injury would the nurse tag as yellow during the triage process? 1) Ankle sprain 2) Hypovolemic shock 3) Open femur fracture 4) Massive head trauma 10. Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident? 1) Less than 10 seconds 2) Less than 15 seconds 3) Less than 30 seconds 4) Less than 60 seconds 11. The nurse is helping devise a training plan to familiarize health-care providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees? 1) Drills 2) Tabletop exercises 3) Access to the policy 4) Computer simulations 12. The nurse is a member of the critical incident stress management unit that looks to meet the psychosocial needs of first responders after a mass casualty incident. Which action by the nurse is appropriate when conducting a session? 1) Arranging group discussion 2) Administering anti-anxiety medication 3) Scheduling individual therapy appointments 4) Documenting individual responses to the session 13. Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems? 1) A motor vehicle accident involving five cars 2) A tornado destroying 50 homes and businesses 3) An act of terrorism injuring and kills hundreds of people 4) A hurricane causing flooding, displacing thousands of people 14. Which organization in the United States mandates ongoing disaster preparedness for hospitals? 1) The Joint Commission (TJC) 2) The local government 3) The state government 4) The Occupational Safety and Health Administration (OSHA) 15. A nurse manager is a member of the emergency response planning team for a hospital located in the Rocky Mountains. Which type of natural disaster will the nurse manager recommend be included in their hospital disaster plan? 1) Tornado 2) Hurricane 3) Avalanche 4) Earthquake 16. The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year? 1) Two 2) Three 3) Four 4) Five 17. The nurse administrator for a long-term care facility is implementing a disaster response plan for staff and residents. Which staff member statements indicate correct understanding of the plan? 1) “We have to implement annual drills.” 2) “Nursing homes are not required to have a plan.” 3) “Our facility is held to the same standards as hospital facilities.” 4) “This is an important component to receive insurance payments for care.” 18. Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks? 1) Anthrax exposure 2) Multi-casualty incidents 3) Mass casualty incidents (MCI) 4) Weapons of mass destruction (WMD) 19. The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a patient who is experiencing hypovolemic shock due to a penetrating wound? 1) Red 2) Black 3) Green 4) Yellow 20. Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? 1) Unlicensed assistive personnel 2) Nurses appointed to a field team 3) A physician who survives the incident 4) Community response team members 21. Which patient injury would receive a black tag by the triage nurse during a mass casualty incident? 1) Concussion 2) Ankle sprain 3) Open femur fracture 4) Full-thickness body burns 22. A green-tagged patient arrives at the emergency department after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this patient? 1) Implementing decontamination measures 2) Performing a head-to-toe physical examination 3) Placing a special bracelet with a disaster number 4) Taking a digital photo and placing it on the medical record 23. Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? 1) Local emergency management system 2) State emergency management system 3) Federal emergency management agency 4) Hospital-level emergency management system 24. Which threats, included in the term “NBC,” lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. 1) Nuclear 2) Biological 3) Botulism 4) Chemical 5) Nipah virus 25. A nurse is working an evening shift when a fire breaks out at the hospital. Which actions by the nurse are appropriate? Select all that apply. 1) Removing patients from immediate danger 2) Discontinuing the use of oxygen for all patients 3) Using a wheelchair to move a bedridden patient 4) Directing ambulatory patients to walk to a safe location 5) Containing the fire immediately to avoid patient evacuation 26. Which nursing actions are necessary when initiating care for patients who have been injured in a natural disaster? Select all that apply. 1) Taking risks 2) Using principles 3) Stepping into the unknown 4) Showing a commanding presence 5) Formulating individualized plans of care 27. Which psychosocial nursing actions are appropriate when providing patient care after a community disaster? Select all that apply. 1) Performing triage of injuries 2) Administering first aid to wounds 3) Offering choices whenever possible 4) Establishing rapport through active listening 5) Requesting assistance from crisis counselors 28. The nurse is contributing to a disaster plan for a possible terrorist attack. Which biological agents should be included in the plan? Select all that apply. 1) Rubella 2) Anthrax 3) Measles 4) Botulism 5) Tularemia 29. Which are the most common types of injuries that should be identified along with treatment options in an organizational disaster plan for the use of explosive devices as agents of terrorism? Select all that apply. 1) Burn 2) Blast 3) Crush 4) Penetration 5) Psychological 30. Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. 1) Treatment 2) Stabilization 3) Evaluation of interventions 4) Formulation of nursing diagnosis 5) Decontamination for suspected contamination 1. A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury? 1) Coughing 2) Soot on the face 3) Singed facial hair 4) Heart rate 98 bpm 2. The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn shock is resolving? 1) Heart rate 112 bpm 2) Respirations 24 per minute 3) Blood pressure 90/60 mm Hg 4) Urine output 800 mL over 2 hours 3. A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if this patient is experiencing carbon monoxide poisoning? 1) Chest x-ray 2) Bronchoscopy 3) Pulse oximeter 4) Carboxyhemoglobin level 4. A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this patient? 1) Increase oral fluids 2) Turn in bed every two hours 3) Monitor strict intake and output 4) Deep breathing and coughing every hour 5. The nurse is caring for a patient who sustained electrical burns. Why should the nurse monitor this patient for compartment syndrome? 1) Potential for undiagnosed injuries 2) Injuries from being thrown bruise soft tissue 3) Electrical current alters integrity of blood vessels 4) Fluid seeps from intravascular spaces into the interstitium 6. The nurse is preparing an educational tool to instruct community members on burn prevention. What should the nurse include as the most common injury in children under age 5? 1) Scald 2) Flame 3) Chemical 4) Carbon monoxide poisoning 7. A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient? 1) Increased zone of stasis 2) Increased zone of hyperemia 3) Increased zone of coagulation 4) Decreased zone of coagulation 8. A patient comes into the emergency room seeking treatment for radiation burns. What should be considered prior to providing care to this patient? 1) Pathway of flow through the body 2) Duration of contact with the agent 3) Type, dose, and length of exposure 4) Temperature to which the skin is heated 9. It is documented that a patient has superficial partial-thickness burns over both anterior lower arms. What should the nurse expect when assessing this patient? 1) Dry with no blisters 2) Waxy appearance and cherry red in color 3) Dry leathery appearance and pale or brown in color 4) Open or closed blisters, mild edema, easily blanches 10. A patient has full-thickness burns over 30% of total body surface area. Which intervention will least likely provide comfort initially to this patient? 1) Elevate injured extremities 2) Medicate for pain around the clock 3) Apply medicated ointment to all areas 4) Elevate the head of the bed 30 degrees 11. A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What should the nurse respond to this patient? 1) “More than two weeks.” 2) “Within one to two weeks.” 3) “Within 24 to 72 hours.” 4) “You will need skin grafts.” 12. The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient? 1) Chest x-ray 2) Bronchoscopy 3) CT scan of the head 4) 12-lead electrocardiogram 13. The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected? 1) Increased pH 2) Increased sodium 3) Increased potassium 4) Decreased hematocrit 14. A patient recovering from deep and full thickness burns is nauseated. Which medication should the nurse provide to help this patient? 1) Ranitidine (Zantac) 2) Esomeprazole (Nexium) 3) Metoclopramide (Reglan) 4) Polyethylene glycol (Miralax) 15. The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicates that additional fluid resuscitation is required? 1) Blood pH 7.39 2) Heart rate 112 bpm 3) Blood pressure 110/60 mm Hg 4) Central venous pressure 2 mm Hg 16. A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment made by the nurse would indicate that wound care treatment has been successful? 1) Gray wound bed 2) Separation of eschar 3) Development of eschar 4) Presence of purulent exudate 17. A patient recovering from full-thickness burns rates pain as a 9 on a scale of 0 to 10 when hydrotherapy is performed. For which type of pain should this patient be treated? 1) Referred 2) Procedural 3) Background 4) Breakthrough 18. The nurse is caring for a patient with 70% total body surface area chemical burns. Which approach should the nurse anticipate to meet this patient’s nutritional needs? 1) Parenteral nutrition 2) Duodenal tube feedings 3) Nasogastric tube feedings 4) Six small high-calorie meals per day 19. A patient recovering from 25% total body surface area burns has a low- grade fever. What should the nurse do to reduce this patient’s risk of developing an infection? 1) Follow contact precautions 2) Implement protective isolation 3) Use sterile technique for all dressing changes 4) Administer prophylactic antibiotics as prescribed 20. The nurse is evaluating nutritional teaching provided to a patient recovering from 24% total body surface area burns. Which information indicates that teaching has been effective? 1) Weight loss 3 kg 2) Serum protein level 7.1 g/dL 3) Serum albumin level 2.8 g/dL 4) +1 pitting edema of lower extremities 21. A patient with 35% total body surface area burns is in the rehabilitative phase of care. Which approach should be used to reduce the risk of developing contractures? 1) Apply splints 2) Physical therapy two hours a day 3) Passive range of motion exercises 4) Occupational therapy one hour every other day 22. A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment? 1) Skin warm and moist 2) Pedal pulses present but faint 3) Scattered areas of scarring noted 4) Nonpitting edema of both ankles 23. An 11-year-old child received burns over both upper and lower arms, both hands, anterior upper and lower legs, anterior chest, and the neck. Using the following as a guide, what is this child’s total body surface area burned? Text Figure 51.8 1) 30 % 2) 42 % 3) 57 % 4) 65 % 24. The nurse is caring for a patient who sustained chemical burns. What would have caused these injuries? Select all that apply. 1) Lime 2) Gasoline 3) Bleach 4) Fabric softener 5) Hydrofluoric acid 25. The school nurse is preparing material for National Fire Prevention week. What information should be added to the classroom posters? Select all that apply. 1) Never leave a burning candle unattended. 2) Set heating pads on “low” when sleeping. 3) Keep a flashlight and telephone near the bed. 4) Check smoke alarm batteries every six months. 5) Never use the oven as a method to warm the home. 26. A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient? Select all that apply. 1) Apply bacitracin ointment 2) Cover with a nonadherent bandage 3) Apply mafenide acetate 10% cream 4) Wash with antiseptic soap and warm water 5) Apply collagenase and cover with roll gauze 27. A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which problems should the nurse anticipate providing continuing care to this patient? Select all that apply. 1) Anxiety 2) Depression 3) Spiritual distress 4) Body image disorder 5) Post-traumatic stress disorder (PTSD) 28. A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much fluid should this patient receive over the first eight hours after the burn occurred? Record your answer as a whole number. 6460 The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat? 1. “Do you work or live near any large power lines?” 2. “Where were you immediately before you got sick?” 3. “Can you write down everything you ate today?” 4. “What other health problems do you have?” The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear? 1. Level A. 2. Level B. 3. Level C. 4. Level D. The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement is the most important fact for the nurse to share with the participants? 1. Health-care facilities should keep masks at entry doors. 2. The respondent should be trained in the proper use of PPE. 3. No single combination of PPE protects against all hazards. 4. The EPA has divided PPE into four levels of protection. The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination? 1. Showers and privacy can be provided to the client in this area. 2. This area isolates the clients who have been exposed to the agent. 3. It provides a centralized area for stocking the needed supplies. 4. It prevents secondary contamination to the health-care providers. The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department? 1. Triage the clients and send them to the appropriate areas. 2. Thoroughly wash the clients with soap and water and then rinse. 3. Remove the clients’ clothing and have them shower. 4. Assume the clients have been decontaminated at the plant. The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation? 1. Contaminated water is the only source of transmission of biological agents. 2. Vaccines are available and being prepared to counteract biological agents. 3. Biological weapons are less of a threat than chemical agents. 4. Biological weapons are easily obtained and result in significant mortality. Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin? 1. A scabby, clear fluid–filled vesicle. 2. Edema, pruritus, and a 2-mm ulcerated vesicle. 3. Irregular brownish-pink spots around the hairline. 4. Tiny purple spots flush with the surface of the skin. The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client’s family? 1. The client should be cremated. 2. Suggest an open casket funeral. 3. Bury the client within 24 hours. 4. Notify the public health department. A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers? 1. Hold their breath as much as possible. 2. Stand up to avoid heavy exposure. 3. Lie down to stay under the exposure. 4. Attempt to breathe through their clothing. The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms should the nurse assess in the client? 1. Anemia, leukopenia, and thrombocytopenia. 2. Sudden fever, chills, and enlarged lymph nodes. 3. Nausea, vomiting, and diarrhea. 4. Flaccid paralysis, diplopia, and dysphagia. Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply. 1. Language difficulties. 2. Religious practices. 3. Prayer times for the people. 4. Rituals for handling the dead. 5. Keeping the family in the designated area. The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take first? 1. Immediately report to the hospital emergency room. 2. Call the American Red Cross to find out where to go. 3. Pack a bag and prepare to stay at the hospital. 4. Follow the nurse’s hospital policy for responding A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster? Nurses and other emergency medical personal A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plant to care for first? A client experiencing a tension pneumothorax A nurse is caring for a client following exposure to inhalational anthrax due to bioterrorism. Which of the following medications should the nurse expect as a common medication to treat anthrax? -Amoxicillin -Doxycycline -Ciprofloxacin A nurse is reviewing treatment protocols for clients exposed to bioterrrorism agents. For which of the following agents should the nurse plan to administer a vaccine following Smallpox A client who is having burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make appropriate? "Tell me more about that." A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury? Lactated Ringers A nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following actions should the nurse plan to take first? Initiate seizure precaution A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as deep partial-thickness burn? The burned area is red in color with eschar present. A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the clients total body surface area? (TBSA) 54% A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. the clients spouse asks the nurse what the procedure entails. Which of the following statements is appropriate? Large incisions will be made in the eschar to improve circulation. A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? Talk with the client during wound care. A nurse is caring for a client who has burns to his face, ears and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? Difficulty swallowing A nurse is caring for a client involved in a suspected bioterrorism event involving exposure to cutaneous anthrax. Which of the following manifestations should the nurse anticipate? Skin lesions with pruritus A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the toal body surface area of the burn injury.What percentage of body surface area should the nurse estimate the clinet has burned? 54% First, determine the burned areas: 1) Entire right and left leg 2) Entire rear torso Next, refer to the Rule of Nines for estimating body surface area Rule of Nines Head: 9% Torso: 36% total (front 18% & back 18%) Arm 9% each Leg 18% each Perineum 1% Apply the Rule of Nines to this client: Left leg = 18% Right leg = 18% Rear torso = 18% Then total all the burned areas: 18 x 3 = 54% A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? Erythema A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take? Pour tepid water over the burns. A nurse is an emergency room is caring a client who sustained partial- thickness burns to both lower legs, chest, face and both forearms. Which of the following is the priority action the nurse should take? Inspect the mouth for sings of inhalation injuries a nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Witch of the following interventions should the nurse anticipate the healthcare provider to prescribe? Place a bed cradle on the client’s bed A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse preform first? Administer IV fluids A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first? An unconscious adult client who has a sucking chest wound, respiration of 38/min, and capillary refill of 2 seconds A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care? A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) First, the nurse should determine the burned areas: Entire left arm Half of right arm Entire front torso Next, the nurse should use the Rule of Nines to estimate the percentage of burned surface area: Head 9% Torso 36% (front 18% and back 18%) Arm 9% each Leg 18% each Perineum 1% Then, the nurse should apply the Rule of Nines to the client's burns: Left arm = 9 % 1/2 of right arm = 4.5 % Front torso = 18 % The total percent of the burned surface area is 9 + 4.5 + 18 = 31.5%. A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? Hyperkalemia A nurse is preparing a response protocol for botulism as bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (Select all that apply) Botulism can produce paralysis within 12 hours to 72 hours following exposure Vomiting and diarrhea are expected findings following exposure A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn? Location of the burn A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet . The nurse should recommend which of the following foods as the best source of protein to promote wound healing? One cup of lentils a nurse is caring for a preschooler who has partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? sensitive to touch wound blanches with pressure blisters A nurse is preparing to start and IV infusion of Lactated Ringer’s for a client who sustained a burn injury. The client is prescribed 5,200 ml of fluid over the first 24 hours. How many mL/hour should the nurse set the pump to infuse for the first 8 hours? 325 ml/hr A nurse assisting with field triage following a motor-vehicle crash involving a bus with multiple victims. The nurse assesses a child who has an open fracture of the femur. Which of the following actions should the nurse take? Place a yellow triage tag on the child A nurse is monitoring a client who was admitted with a sever burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? Heart Rate A nurse is caring for a client who full-thickness burns all over 75% of his body. Which of the following methods is appropriate to accurately monitor the cardiovascular system? Monitor the pulmonary artery pressure A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make? He has an electrical burn. He is stable, and we will update you with any changes. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness bur