Advanced med surg Flashcards
A nurse in a burn treatment center is caring for a client who is admitted with
severe burns to both lower extremities and is pending an escharotomy. The client’s
spouse asks the nurse what the procedure entails. Which of the following
nursing statements is appropriate?
a.“large incisions will be made in the eschar to improve circulation”
b. “ I can call the doctor back here if you want me to”
c. “a piece of skin will be removed and grafted over the burned area”
d. “dead tissue will be surgically removed”
A- “Large incisions will be made in the eschar to improve circulation.”
A nurse is monitoring the fluid replacement of a client who has sustained burns.
Which of the following fluids is used in the first 24 hours following a burn injury?
a. 5% dextrose in water
b. 5% dextrose in normal saline
c. normal saline
d. lactated ringers
D- lactated ringers
A nurse is caring for a client who has full-thickness burns all over 75% of his
body. Which of the following methods is appropriate to accurately monitor the
cardiovascular system?
a. auscultates cuff blood pressure.
b. palpate pulse pressure
c. obtains a central venous pressure.
d. monitors the pulmonary artery pressure.
C- obtains a central venous pressure.
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?
a. Age of the client
b. Associated medical history
c. Location of the burn
d. Cause of the burn
d. Cause of the burn
A client arrives at the emergency dept following an explosion at the chemical
plant. He has deep partial and full-thickness chemical burns over more than 25 %
of his body surface area. What is the nurse’s priority intervention?
a. Initiate fluid resuscitation
b. Medication for pain
c. Administer antibiotics.
d. Maintain a patent airway.
d. Maintain a patent airway.
A nurse is caring for a client who came the emergency dept reporting chest pain.
The provider suspects a myocardial infarction. While waiting for the laboratory to
report the client’s troponin levels, the client asks what this blood test will show.
The nurse should explain that troponin is
a. An enzyme that indicates damage to brain, heart, and skeletal muscle
tissues
b. A protein whose levels reflect the risk for coronary artery disease
c. A heart muscle protein that appears in the bloodstream when there is
damage to the heart
d. A protein that helps transport oxygen throughout the body
c. A heart muscle protein that appears in the bloodstream when there is
damage to the heart
A nurse is assessing a client who has disseminated intravascular coagulation
(DIC). Which of the following should the nurse expect in the findings?
a. Excessive thrombosis and bleeding
b. Progressive increase in platelet production
c. Immediate sodium and fluid retention
d. Increased clotting factors
d. Increased clotting factors
A nurse is about to administer warfarin (Coumadin) to a client who has atrial
fibrillation. When the client asks what his medication will do, which of the
following is an appropriate nursing response?
a. It helps convert atrial fibrillation to sinus rhythm
b. Is dissolves clots in the bloodstream
c. It slows the response of the ventricles to the fast atrial impulses.
d. It prevents strokes in clients who have atrial fibrillation.
d. It prevents strokes in clients who have atrial fibrillation.
A nurse in a cardiac care unit is caring for a client with acute heart failure. Which
of the following findings should the nurse expect?
a. Decreased brain natriuretic peptide (BNP)
b. Elevated central venous pressure (CVP)
c. Decreased pulmonary pressure
d. Increases urinary output
b. Elevated central venous pressure (CVP)
A client comes into the ED reporting nausea and vomiting that worsens when
lying down and without relief from antacids. The provider suspects acute
pancreatitis. Which of the following lab test results should the nurse expect to see if
the client has acute pancreatitis?
a. Decreased WBC
b. Increased serum amylase
c. Decreased serum lipase
d. Increased serum calcium
b. Increased serum amylase
A nurse in the ICU is caring for a client who has acute respiratory distress
syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The
provider plans to extubate her within the next 24 hour. Which of the following is
an important criterion for extubating the client?
a. Ability to cough effectively
b. Adequate tidal volume without manually assisted breaths
c. No indication of infection
d. No need for supplemental oxygen
b. Adequate tidal volume without manually assisted breaths
A nurse is caring for a client following a CT scan with dye who suffered from an
anaphylactic reaction. Which of the following conditions requires a priority nursing
response?
b. stridor
A nurse is caring for a female client who came in to the ED reporting SOB and
pain in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood
pressure 140/80 m8juiimHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg,
PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the
priority intervention?
a. Prepare for mechanical ventilation
b. Administer oxygen via face mask
c. Prepare to administer a sedative
d. Monitor for pulmonary embolism
b. Administer oxygen via face mask
A nurse is monitoring a client who has just had a thoracentesis to remove pleural
fluid. Which of the following clinical manifestations indicate a complication that
requires notifying the provider immediately?
a. Serosanguineous drainage from the puncture site
b. Discomfort at the puncture site
c. Increased heart rate
d. Decreased temperature
c. Increased heart rate
A group of college students was attending a weekend football rally when one of
the students stumbled and fell into the bonfire. Although several friends quicklyintervened, the client sustained partial-thickness burns to both lower legs, chest,
and both forearms. Which of the following is priority nursing action when the
client is brought to the ED?
a. cover the burned area with sterile gauze
b. inspect mouth for signs of inhalation
c. administer intravenous pain medication
d. draw blood for a CBC
b. inspect mouth for signs of inhalation.
