nur265 exam 3 shock-burn chpt 26,37 Latest
Update 2025-2026 50 Questions and 100%
Verified Correct Answers Guaranteed A+
1. A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs
250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate
does the nurse set the IV pump? (Record your answer using a whole number.) ____
mL/hr - CORRECT ANSWER: 142 mL/hr
The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30
mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr
(3409/24 = 142).
DIF: Analyzing/Analysis REF: 747
KEY: IV fluids| fluid and electrolyte imbalance| critical rescue| sepsis| shock
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies
1. A nurse cares for a client with burn injuries during the resuscitation phase. Which
actions are priorities during this phase? (Select all that apply.)
a.
Administer analgesics.
b.
Prevent wound infections.
c.
Provide fluid replacement.
d.
Decrease core temperature.
e.
Initiate physical therapy. - CORRECT ANSWER: A, B, C
,Nursing priorities during the resuscitation phase include securing the airway, supporting
circulation and organ perfusion by fluid replacement, keeping the client comfortable with
analgesics, preventing infection through careful wound care, maintaining body
temperature, and providing emotional support. Physical therapy is inappropriate during
the resuscitation phase but may be initiated after the client has been stabilized.
DIF: Applying/Application REF: 473
KEY: Skin lesions/wounds| pharmacologic pain management| infection control
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of
Care
1. A student is caring for a client who suffered massive blood loss after trauma. How
does the student correlate the blood loss with the client's mean arterial pressure (MAP)?
a.
It causes vasoconstriction and increased MAP.
b.
Lower blood volume lowers MAP.
c.
There is no direct correlation to MAP.
d.
It raises cardiac output and MAP. - CORRECT ANSWER: B
Lower blood volume will decrease MAP. The other answers are not accurate.
DIF: Remembering/Knowledge REF: 740
KEY: Mean arterial blood pressure| shock
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
1. An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00
this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at
which the nurse should infuse intravenous fluid resuscitation when started at noon.
,(Record your answer using a whole number.) _____ mL/hr - CORRECT ANSWER: 1500
mL/hr
The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs
18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid
replacement needs to be administered during the first 8 hours after injury, and half
during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started
until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500
mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn
hours.
DIF: Applying/Application REF: 478
KEY: Medication calculation
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies
1. The registered nurse assigns a client who has an open burn wound to a licensed
practical nurse (LPN). Which instruction should the nurse provide to the LPN when
assigning this client?
a.
"Administer the prescribed tetanus toxoid vaccine."
b.
"Assess the client's wounds for signs of infection."
c.
"Encourage the client to breathe deeply every hour."
d.
"Wash your hands on entering the client's room." - CORRECT ANSWER: D
Infection can occur when microorganisms from another person or from the environment
are transferred to the client. Although all of the interventions listed can help reduce the
risk for infection, handwashing is the most effective technique for preventing infection
transmission.
DIF: Applying/Application REF: 466
, KEY: Infection control| Standard Precautions| collaboration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of
Care
1. The student nurse studying shock understands that the common manifestations of
this condition are directly related to which problems? (Select all that apply.)
a.
Anaerobic metabolism
b.
Hyperglycemia
c.
Hypotension
d.
Impaired renal perfusion
e.
Increased perfusion - CORRECT ANSWER: A, C
The common manifestations of shock, no matter the cause, are directly related to the
effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal
function, and increased perfusion are not manifestations of shock.
DIF: Remembering/Knowledge REF: 741
KEY: Shock| pathophysiology MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A nurse receives new prescriptions for a client with severe burn injuries who is
receiving fluid resuscitation per the Parkland formula. The client's urine output continues
to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?
a.
Increase intravenous fluids by 100 mL/hr.
Update 2025-2026 50 Questions and 100%
Verified Correct Answers Guaranteed A+
1. A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs
250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate
does the nurse set the IV pump? (Record your answer using a whole number.) ____
mL/hr - CORRECT ANSWER: 142 mL/hr
The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30
mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr
(3409/24 = 142).
DIF: Analyzing/Analysis REF: 747
KEY: IV fluids| fluid and electrolyte imbalance| critical rescue| sepsis| shock
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies
1. A nurse cares for a client with burn injuries during the resuscitation phase. Which
actions are priorities during this phase? (Select all that apply.)
a.
Administer analgesics.
b.
Prevent wound infections.
c.
Provide fluid replacement.
d.
Decrease core temperature.
e.
Initiate physical therapy. - CORRECT ANSWER: A, B, C
,Nursing priorities during the resuscitation phase include securing the airway, supporting
circulation and organ perfusion by fluid replacement, keeping the client comfortable with
analgesics, preventing infection through careful wound care, maintaining body
temperature, and providing emotional support. Physical therapy is inappropriate during
the resuscitation phase but may be initiated after the client has been stabilized.
DIF: Applying/Application REF: 473
KEY: Skin lesions/wounds| pharmacologic pain management| infection control
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of
Care
1. A student is caring for a client who suffered massive blood loss after trauma. How
does the student correlate the blood loss with the client's mean arterial pressure (MAP)?
a.
It causes vasoconstriction and increased MAP.
b.
Lower blood volume lowers MAP.
c.
There is no direct correlation to MAP.
d.
It raises cardiac output and MAP. - CORRECT ANSWER: B
Lower blood volume will decrease MAP. The other answers are not accurate.
DIF: Remembering/Knowledge REF: 740
KEY: Mean arterial blood pressure| shock
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
1. An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00
this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at
which the nurse should infuse intravenous fluid resuscitation when started at noon.
,(Record your answer using a whole number.) _____ mL/hr - CORRECT ANSWER: 1500
mL/hr
The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs
18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid
replacement needs to be administered during the first 8 hours after injury, and half
during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started
until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500
mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn
hours.
DIF: Applying/Application REF: 478
KEY: Medication calculation
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies
1. The registered nurse assigns a client who has an open burn wound to a licensed
practical nurse (LPN). Which instruction should the nurse provide to the LPN when
assigning this client?
a.
"Administer the prescribed tetanus toxoid vaccine."
b.
"Assess the client's wounds for signs of infection."
c.
"Encourage the client to breathe deeply every hour."
d.
"Wash your hands on entering the client's room." - CORRECT ANSWER: D
Infection can occur when microorganisms from another person or from the environment
are transferred to the client. Although all of the interventions listed can help reduce the
risk for infection, handwashing is the most effective technique for preventing infection
transmission.
DIF: Applying/Application REF: 466
, KEY: Infection control| Standard Precautions| collaboration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of
Care
1. The student nurse studying shock understands that the common manifestations of
this condition are directly related to which problems? (Select all that apply.)
a.
Anaerobic metabolism
b.
Hyperglycemia
c.
Hypotension
d.
Impaired renal perfusion
e.
Increased perfusion - CORRECT ANSWER: A, C
The common manifestations of shock, no matter the cause, are directly related to the
effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal
function, and increased perfusion are not manifestations of shock.
DIF: Remembering/Knowledge REF: 741
KEY: Shock| pathophysiology MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A nurse receives new prescriptions for a client with severe burn injuries who is
receiving fluid resuscitation per the Parkland formula. The client's urine output continues
to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?
a.
Increase intravenous fluids by 100 mL/hr.
