quiz 5 Flashcards
- A 15-year-old male who is allergic to peanuts eats a peanut butter cup. He then goes into anaphylactic shock. Which assessment findings will the nurse assess forjhhuy7
A. Hypertension, anxiety, and tachycardia
B. Bradycardia, decreased arterial pressure, and oliguria
C. Bronchoconstriction, hives or edema and hypotension
D. Fever, hypotension, and erythematous rash
C. Bronchoconstriction, hives or edema and hypotension
- A 20-year-old female is being admitted to the hospital with fever and septic shock. Which set of assessment findings would the nurse expect the patient to exhibit?
A. Reduced cardiac output, increased systemic vascular resistance, moist cough
B. Bradycardia, palpitations, confusion, truncal rash
C. Severe respiratory distress, JVD, chest pain
D. Low BP and tachycardia
low bp and tachycardia
- A 28-year-old male is admitted to the burn unit 2 hours after receiving second- and third-degree burns over 50% of his body surface in an industrial explosion. Abnormal vital signs include low blood pressure and tachycardia. Lab results show a high hematocrit due to:
A. fluid movement out of the vascular space
B. increased vascular protein secondary to increased metabolism
C. sickle cell syndrome
D. kidney failure
A. fluid movement out of the vascular space
- A 75-year-old female has been critically ill with multiple organ dysfunction syndrome (MODS) for longer than a week and has developed a severe oxygen supply and demand imbalance. What statement best describes this imbalance?
A. Increased oxygen deliver to cells to meet decreased oxygen demands
B. the oxygen reserve has been exhausted, leaving oxygen consumption dependent on what amount the circulation is able to deliver
C. the amount of oxygen consumed by cells depends only on the needs of cells, because there is oxygen in reserve
D. the situation results in supply-independent consumption
B. the oxygen reserve has been exhausted, leaving oxygen consumption dependent on what amount the circulation is able to deliver
- For an infection to progress to septic chock, what must occur?
A. the individual must be immunosuppressed
B. bacteria must enter the bloodstream
C. the infection must be gram negative
D. the myocardium must be impaired
B. bacteria must enter the bloodstream
- Hypovolemia in the early stages of burn shock is directly related to:
A. decreased cardiac contractility and shunting of blood away from visceral organs
B. bacterial infection of the wound and resulting bacteremia
C. increased capillary permeability and evaporative water loss
D. hypometabolism and renal water loss
C. increased capillary permeability and evaporative water loss
- Neurogenic shock can be caused by any factor that inhibits the
A. somatic nervous system
B. thalamus
C. sympathetic nervous system
D. parasympathetic nervous system
C. sympathetic nervous system
- Six hours after a thermal burn covering 50% of a client’s total body surface area (TBSA), the nurse obtains these data when assessing a client. Which of the following information is priority for the nurse to communicate to the health care provider?
A. BP is 94/46 per arterial line
B. urine output is 20mL/hour for the past 2hrs
C. serous exudate is leaking from the burns
D. cardiac monitor shows a pulse rate of 104
B. urine output is 20mL/hour for the past 2hrs
- The charge nurse is evaluating the skills of a new RN caring for a client in shock. Which of the following actions by the new RN indicates a need for more education in the care of clients with shock?
A. Increasing the nitroprusside infusion rate for a client with a high SVR
B. keeping the head of the bed flat for a client with hypovolemic shock
C. decreasing the room temp to 20C for a client with neurogenic shock
D. placing the pulse oximeter on the ear for a client with septic shock
C. decreasing the room temp to 20C for a client with neurogenic shock
- The nurse is admitting a client to the burn unit who has burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. Which of the following actions should the nurse implement first?
A. reposition the client in high-fowler’s position and reassess breath sounds
B. document the results and continue to monitor the client’s respiratory rate
C. encourage the client to cough and auscultate the lungs again
D. notify the HCP and prepare for endotracheal intubation
D. notify the HCP and prepare for endotracheal intubation
- The nurse is admitting a client with extensive electrical burn injuries. Which of the following prescribed interventions should the nurse implement first?
A. apply dressings to burned areas
B. start two large bore IVs
C. Place on cardiac monitor
D. assess for pain at contact points
C. Place on cardiac monitor
- The nurse is caring for a client who has burns on the back and chest from a house fire and has become agitated and restless 9 hours after being admitted to the hospital. Which of the following actions should the nurse take first?
A. use pulse oximetry to check the oxygen saturation
B. administer the ordered morphine sulphate IV
C. stay at the bedside and reassure the client
D. assess orientation and level of consciousness
A. use pulse oximetry to check the oxygen saturation
- The nurse is caring for a client who has circumferential burns of both arms and develops a decrease in radial pulse strength and numbness in the fingers. Which of the following actions should the nurse take?
A. notify the HCP
B. elevate both arms above heart level with pillows
C. encourage the client to flex and extend the fingers
D. monitor the pulses every 2hrs
A. notify the HCP
- The nurse is caring for a client who has deep partial-thickness and full-thickness burns of the face and chest and is having the wounds treated with the open method. Which of the following nursing actions should be included in the plan of care?
A. turn the room temp up to at least 20C during dressing changes
B. administer prophylactic antibiotics to prevent bacterial colonization
C. restrict all visitors to prevent cross-contamination of wounds
D. wear gowns, caps, masks, and gloves during all care of the client
D. wear gowns, caps, masks, and gloves during all care of the client
- The nurse is caring for a client who has partial-thickness burns. Which of the following prescribed medications will be best for the nurse to use before wound debridement?
A. lorazepam
B. gabapentin
C. hydromorphone
D. ketorolac
C. hydromorphone
