WorksheetsNR341 W5_Trauma, Burns, Emergency & Disaster Nursing
Total questions: 100
Worksheet time: 52mins
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. Which term would the nurse use to document the burn depth?
First-degree skin destruction
Full-thickness skin destruction
Superficial partial-thickness skin destruction
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which prescribed action would be the nurse’s priority?
Monitoring urine output
Scheduling additional laboratory tests
Increasing the rate of the ordered IV solution
Typing and crossmatching for a blood transfusion
A patient is admitted with burns to the head, face, and hands. Initially, wheezes are heard throughout the chest, but an hour later, the lung sounds are decreased, and no wheezes are audible. Which action would the nurse take?
Encourage the patient to cough and auscultate the lungs again.
Notify the health care provider and prepare for endotracheal intubation.
Document the assessment and continue to monitor the patient’s respiratory rate.
Reposition the patient in high-Fowler‘s position and reassess breath sounds.
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, at what rate would the nurse infuse the IV fluids?
219 mL/hr
625 mL/hr
938 mL/hr
During the emergent phase of burn care, which assessment is most useful in determining whether the patient is receiving adequate fluids?
Check skin turgor.
Monitor daily weight.
Assess mucous membranes.
Measure hourly urine output.
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. Which action would the nurse plan to take to maintain adequate patient nutrition?
Administer vitamins and minerals intravenously.
Insert a feeding tube and initiate enteral nutrition.
Infuse total parenteral nutrition via a central catheter.
Encourage an oral intake of at least 5000 kcal per day.
Which nursing action prevents cross-contamination when the patient's full-thickness burn wounds are exposed?
Using sterile gloves when removing dressings
Keeping the room temperature at 70°F (20°C)
Wearing gown, cap, mask, and gloves during care
Giving IV antibiotics to prevent bacterial colonization
A nurse is caring for a patient who has burns on the ears, head, neck, and right arm and hand. In which position would the nurse place the patient?
Place the right arm and hand flexed in a position of comfort.
Elevate the right arm and hand on pillows and extend the fingers.
Assist the patient to a supine position with a small pillow under the head.
Position the patient in a side-lying position with rolled towel under the neck.
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and reports numbness in the toes. Which action would the nurse take first?
Monitor thepulses every hour.
Notify the health care provider.
Elevate both legs above heart level with pillows.
Encourage the patient to flex and extend the toes.
Esomeprazole is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?
Bowel sounds
Stool frequency
Stool occult blood
Abdominal distention
Which prescribed drug would the nurse plan to administer before scheduled wound debridement on a patient with partial-thickness burns?
ketorolac
lorazepam (Ativan)
gabapentin (Neurontin)
hydromorphone (Dilaudid)
A young female patient with deep partial-thickness face and neck burns is in the rehabilitation phase. Which statement by the patient indicates that a problem with body image is resolving?
“I‘m glad to know thescars will be gone soon.”
“I don‘t use a pillow, so my neck will be OK.”
“I think dark beige makeup will cover this scar.”
“I don‘t think my boyfriend will want to look at me now.”
A patient admitted with burns over 30% of the body surface 3 days ago has dramatically increased urine output today. How would the nurse interpret this finding?
Diuresis indicates development of acute kidney injury.
Diuresis reflects normalizing capillary permeability.
Increased urine volume signals a likely urinary infection.
Increased urine volume requires increased calorie intake.
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would the nurse recommend as providing the most support for wound healing?
Banana
Orange gelatin
Vanilla milkshake
Whole grain bagel
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. Which assessment is the priority?
Oral temperature
Peripheral pulses
Extremity movement
Pupil reaction to light
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action would the nurse take first?
Stay at the bedside and reassure the patient. at the bedside
Administer the ordered morphine sulfate IV.
Assess orientation and level of consciousness.
Use pulse oximetry to check oxygen saturation.
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action would the nurse take first?
Auscultate for breath sounds.
Determine the extent and depth of the burns.
Give the prescribed hydromorphone (Dilaudid).
Infuse the prescribed lactated Ringer‘s solution.
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention would the nurse implement first?
Assess pain level.
Place on heart monitor.
Check potassium level.
Assess oral temperature.
A patient who weighs 92 kg (202.4 lb) experienced a thermal burn covering 50% of total body surface area (TBSA) eight hours ago. Which new information would be a priority for the nurse to communicate to the health care provider?
Blood pressure is 95/48 per arterial line.
Urine output of 41 mL over past 2 hours.
Serous exudate is leaking from the burns.
Heart monitor shows sinus tachycardia of 108.
Which patient would the nurse assess first?
A patient with burns who reports level 8 (0 to 10 scale) pain
A patient with smoke inhalation who has wheezes and confusion
A patient with full-thickness leg burns who is scheduled for a dressing change
A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr
Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit?
A patient who has twice-daily burn debridements to partial-thickness facial burns
A patient who just returned from having a cultured epithelial autograft to the chest
A patient who has a 15% weight loss from admission and will need enteral feedings
A patient who has blebs under an autograft on the thigh and has an order for bleb aspiration
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. Which action would the nurse take first?
Insert two large-bore IV lines.
Check the patient's orientation.
Place the patient on 100% O2.
Assess for percentage of burn injury.
The nurse is reviewing laboratory results for a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?
Hematocrit of 53%
Serum sodium of 147 mEq/L
Serum potassium of 6.1 mEq/L
Blood urea nitrogen of 37 mg/dL
The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse?
The new nurse uses clean gloves when applying antibacterial cream to a burn wound.
The new nurse obtains burn cultures when the patient has a temperature of 95.2°F
(35.1°C).
The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change.
The new nurse calls the health care provider when a nondiabetic patient‘s serum glucose is elevated.
Which nursing action is a priority for a patient who had a burn injury while working on an electrical power line?
Inspect the contact burns.
Check the blood pressure.
Stabilize the cervical spine.
Assess alertness and orientation.
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?
Keep the arms in a position of comfort.
Apply water-based cream to healing areas.
Avoid theuse of sustained-release opioids.
Teach about the purpose of tetanus immunization.
A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, “I‘m sorry that I‘m still alive. My life will never be normal again.” Which response should the nurse provide?
“Most people recover after a burn and feel satisfied with their lives.”
“It‘s true that your life may be different. What concerns you the most?”
“Why do you feel that way? It will get better as your recovery progresses.”
“It is really too early to know how much your life will be changed by the burn.”
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to theburn unit. Using theParkland formula of 4 mL/kg/%TBSA, what is theIV infusion rate (mL/hour) for lactated Ringer‘s solution that thenurse will give during thefirst 8 hours?
(a) mL
The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured? (a) %
After change-of-shift report, which patient would the nurse assess first?
A 40-yr-old with a pleural effusion who reports severe stabbing chest pain
A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion
A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101F
(38.3C)
An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action would the nurse take?
Turn and reposition the patient.
Administer prescribed morphine.
Clamp the chest tube in two places.
Assist the patient with incentive spirometry.
A patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next?
Auscultate the bowel sounds.
Prepare the patient for surgery.
Check the patient‘s oral temperature.
Obtain information about the accident.
Using the Emergency Severity Index (ESI) levels 1, 2, 3, 4, or 5, select the correct choices with the appropriate triage for the following patient situations presented in an emergency department (ED).
2 → a. A 6-year-old child with a temperature of 103.2°F (39.6°C)
1_ → b. A 22-year-old woman with asthma in acute respiratory distress
2 → c. An infant who has been vomiting for 2 days
4 → d. A 50-year-old man with low back pain and spasms
1_→ a. A 6-year-old child with a temperature of 103.2°F (39.6°C)
2_→ b. A 22-year-old woman with asthma in acute respiratory distress
4_→ c. An infant who has been vomiting for 2 days
3_→ d. A 50-year-old man with low back pain and spasms
Using the Emergency Severity Index (ESI) levels 1, 2, 3, 4, or 5, select the correct choices with the appropriate triage for the following patient situations presented in an emergency department (ED).
1 → a. A 32-year-old woman who is unconscious following an automobile accident
5→ b. A 40-year-old woman with rhinitis and a cough
2→ c. A 58-year-old man with midsternal chest pain
3→ d. A 16-year-old teenager with an angulated forearm following a sports injury
4 → a. A 32-year-old woman who is unconscious following an automobile accident
3→ b. A 40-year-old woman with rhinitis and a cough
5→ c. A 58-year-old man with midsternal chest pain
1→ d. A 16-year-old teenager with an angulated forearm following a sports injury
When a nurse is performing a primary survey in the ED, what is being assessed?
Whether the personnel of the ED are adequate to treat the patient
The acuity of the patient’s condition to determine priority of care
Whether the patient is responsive enough to provide needed information
The status of airway, breathing, circulation, disability, and exposure/environmental control
During the primary survey, the nurse observes asymmetric chest wall movement. What intervention would the nurse do first?
Check a central pulse.
Stabilize the cervical spine.
Apply direct pressure to the wound.
Start bag-mask ventilation with 100% oxygen.
During the secondary survey of a trauma patient in the ED, why is it important that the nurse obtain details of the incident?
The mechanism of injury can predict specific injuries.
Key facts may be forgotten when needed later for legal actions.
Alcohol use associated with many accidents can affect treatment of injuries.
Many types of accidents or trauma must be reported to government agencies.
What nursing intervention is done during the “E” step of the primary survey?
Obtain full set of vital signs.
Remove the patient’s clothing and assess.
Elicit history and head-to-toe assessment.
Assess mental status and capillary refill for signs of shock.
When is the placement of a nasogastric tube contraindicated during emergency care?
Inhalation injury
Head or facial trauma
Intraabdominal bleed
Cervical spine fracture
In assessing the emergency patient’s health history, what information is obtained using the mnemonic SAMPLE?
Skin, anatomy of injuries, mucous membranes, peripheral edema, leukocytosis, eczema location
Stiffness, approximate weight, motor function, palpable swelling, labored breathing, edema severity
Symptoms, allergies, medications, past health history, last meal, and events/environment leading to the illness or injury
Sentience, abdominal sounds, memory loss, people exposed to, last medication, earliest availability of past medical records
A 63-year-old trauma patient has open wounds, and the nurse asks the patient about her tetanus immunization status. Which situation would tetanus and diphtheria toxoids with acellular pertussis (Tdap) vaccine be given to the patient?
Had 3 doses of tetanus toxoid as a child
Has had a dose of tetanus toxoid in the past 10 years
Is unsure of the history of tetanus toxoid vaccinations
Has not had a dose of tetanus toxoid in the past 3 years
After the death of a 36-year-old man from a massive head injury, what would be appropriate for the ED nurse to do?
Ask the family members to consider donating their loved one’s organs.
Notify an organ procurement agency that a death has occurred that could result in organ donation.
Explain to the family what a generous act it would be to donate the patient’s organs to another patient who needs them.
Ask the family to check the patient’s driver’s license to determine whether he had designated approval of donation of his organs in case of death.
What heat-related emergency would the healthy athlete with inadequate fluid intake be most likely to experience after exercise?
Heatstroke
Heat attack
Heat cramps
Heat exhaustion
Which statements describe heat exhaustion? Select all that apply.
Volume and electrolyte depletion
Treated with rapid cooling methods
High risk of mortality and morbidity
Rectal temperature of 99.6°F to 104°F (37.5°C to 40°C)
Causes mild confusion, diaphoresis, and dilation of pupils
What is the first priority in managing the patient after drowning?
Reversing acidosis
Correcting hypoxia
Maintaining fluid balance
Preventing cerebral edema
A patient was bitten by the neighbor’s dog 8 hours ago. What treatment would the nurse plan to provide?
Report the bite to the police.
Give rabies prophylaxis.
Start prophylactic IV antibiotics.
Dress the wound to prevent exposure to neurotoxins.
The patient is admitted with severe acidosis after trying to commit suicide by ingesting aspirin. What would be used to treat this patient?
Milk
Cathartics
Hemodialysis
Whole bowel irrigation
The nurse is doing the primary survey of an adult who was in a motor vehicle collision. After the nurse determines that the patient has an unobstructed airway, which action would the nurse take next?
Palpate extremities for bilateral pulses.
Observe the patient‘s respiratory effort.
Check thepatient‘s level of consciousness.
Examine thepatient for external bleeding.
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?
Send blood to the lab for a complete blood count.
Assess further for a cause of the decreased circulation.
Finish the airway, breathing, circulation, and disability survey.
Start normal saline fluid infusion with two large-bore IV lines.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. Which action would the nurse complete during the primary survey of the patient?
Obtain a complete set of vital signs.
Check a Glasgow Coma Scale score.
Attach an electrocardiogram monitor.
Ask about chronic medical conditions.
A 19-yr-old patient presents to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. the patient denies having any previous vaccinations. What would the nurse anticipate administering?
Tetanus immunoglobulin (TIG) only
TIG and tetanus-diphtheria toxoid (Td)
Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only
TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)
A patient who experienced blunt abdominal trauma during a motor vehicle collision reports increasing abdominal pain. For which procedure would the nurse expect to prepare the patient?
Peritoneal lavage
Abdominal ultrasonography
Nasogastric (NG) tube placement
Magnetic resonance imaging (MRI)
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective?
“I‘ll take salt tablets when I work outdoors in the summer.”
“I should take acetaminophen (Tylenol) if I start to feel too warm.”
“I need to drink extra fluids when working outside in hot weather.”
“I‘ll move to a cool environment if I notice that I‘m feeling confused.”
A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for thenurse to take during theobservation period?
Assess heart sounds.
Palpate peripheral pulses.
Check mental orientation.
Auscultate breath sounds.
A patient arrives in the emergency department (ED) several hours after taking “25 to 30” acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
Administer N-acetylcysteine.
Prepare for chelation therapy.
Start oxygen using a non-rebreather mask.
Have the patient drink large amounts of water.
A triage nurse in a busy emergency department (ED) assesses a patient who reports 7/10 abdominal pain and states, “I had a temperature of 103.9°F (39.9°C) at home.” Which action would the nurse take first?
Administer acetaminophen (Tylenol).
Assess the patient‘s current vital signs.
Ask the patient to provide a clean-catch urine for urinalysis.
Tell the patient that it may be 2 hours before seeing a health care provider.
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient requires the most immediate treatment?
A patient with no pedal pulses
A patient with an open femur fracture
A patient with paradoxical chest motion
A patient with bleeding facial lacerations
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action would the nurse take first?
Apply ice packs to both hands.
Attempt to remove the patient‘s rings.
Apply calamine lotion to itching areas.
Give prescribed diphenhydramine (Benadryl).
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action would the nurse plan to take first?
Insert a large-bore orogastric tube.
Assist with endotracheal intubation.
Prepare a 60-mL syringe with saline.
Give first dose of activated charcoal.
A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action would the nurse take first?
Obtain the patient‘s vital signs.
Obtain a baseline complete blood count.
Brush visible powder from the skin and clothing.
Decontaminate the patient by showering with water.
An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. the patient‘s core temperature is 105.4°F (40.8°C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. Which action would the nurse plan to take?
Apply wet sheets and a fan to the patient.
Provide O2 at 2 L/min with a nasal cannula.
Start lactated Ringer‘s solution at 1000 mL/hr.
Give acetaminophen (Tylenol) rectal suppository.
An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
Pulse
Heart rhythm
Breath sounds
Body temperature
Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which color tag indicates that the nurse need to assess that patient first?
Red
Blue
Black
Yellow
Family members are in the patient‘s room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action would the nurse take first?
Keep the family in the room and assign a staff member to explain the care given and answer questions.
Ask the family to wait outside the patient‘s room with a staff member to provide emotional support.
Ask the family members whether they would prefer to remain in the patient‘s room or wait outside the room.
Tell the family members that patients are comforted by having family members
present during resuscitation efforts.
A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?
Prepare to administer rabies immune globulin.
Assist thehealth care provider with suturing the wounds.
Teach the patient about the use of prophylactic antibiotics.
Keep the wounds dry until the health care provider can assess them.
The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
Use tweezers to remove any remaining ticks.
Check the vital signs, including temperature.
Give doxycycline (Vibramycin) 100 mg orally.
Obtain information about recent outdoor activities.
Which interventions will thenurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.)
Assist with endotracheal intubation.
Insert an indwelling urinary catheter.
Begin continuous cardiac monitoring.
Prepare to give sympathomimetic drugs.
Obtain a prescription for patient restraints.
The emergency department (ED) nurse is starting targeted temperature
management/therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.)
Evaluate changes in heart rhythm.
Insert a urinary catheter to drainage.
Assess neurologic status every 2 hours.
Place cooling blankets above and below patient.
Attach rectal temperature probe to cooling blanket control panel.
An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which data would indicate to the nurse that the goals of IABP treatment are being met?
Urine output of 25 mL/hr
Heart rate of 110 beats/min
Cardiac output (CO) of 5 L/min
Stroke volume (SV) of 40 mL/beat
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
Check temperature every 2 hours.
Monitor breath sounds frequently.
Maintain patient in supine position.
Assess skin for flushing and itching.
A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?
No heart murmur
Skin is warm and pink
Decreased troponin level
Blood pressure of 92/40 mm Hg
Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?
The patient‘s serum creatinine level is elevated.
The patient reports intermittent chest pressure.
The patient‘s extremities are cool and pulses are weak.
The patient has bilateral crackles throughout lung fields.
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data would be of most concern to the nurse?
Urine output is 30 mL/hr.
Blood pressure is 90/40 mm Hg.
Oral fluid intake is 100 mL for 8 hours.
Skin tenting over the sternum is prolonged.
After receiving change-of-shift report for several patients with neutropenia, which patient would the nurse assess first?
A 23-yr-old who reports severe fatigue
A 56-yr-old with frequent explosive diarrhea
A 33-yr-old with a fever of 100.8°F (38.2°C)
A 66-yr-old who has white pharyngeal lesions
An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which data would indicate to the nurse that the goals of IABP treatment are being met?
Urine output of 25 mL/hr
Heart rate of 110 beats/min
Cardiac output (CO) of 5 L/min
Stroke volume (SV) of 40 mL/beat
After change-of-shift report in the progressive care unit, for which patient would the nurse provide care first?
Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases
Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute
Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics
Patient admitted with anaphylaxis 3 hours ago who has clear lung sounds and a blood pressure of 108/58 mm Hg
An 81-yr-old patient who has been in the intensive care unit (ICU) for a week with sepsis is
now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion with stable vital signs and oxygen saturation. What would the nurse plan to do?
Give PRN lorazepam (Ativan) and cancel the transfer.
Inform the receiving nurse and then transfer the patient.
Notify the health care provider and postpone the transfer.
Obtain an order for restraints as needed and transfer the patient.
Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient‘s left ventricular afterload?
Mean arterial pressure (MAP)
Systemic vascular resistance (SVR)
Pulmonary vascular resistance (PVR)
Pulmonary artery wedge pressure (PAWP)
After surgery for an abdominal aortic aneurysm, a patient‘s central venous pressure (CVP) monitor indicates low pressures. Which action would the nurse take?
Administer IV diuretic medications.
Increase the IV fluid infusion per protocol.
Increase the infusion rate of IV vasodilators.
Elevate the head of the patient‘s bed to 45 degrees.
When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment?
Central venous pressure (CVP)
Systemic vascular resistance (SVR)
Pulmonary vascular resistance (PVR)
Pulmonary artery wedge pressure (PAWP)
When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, which is the most pertinent measurement for the nurse to obtain?
Central venous pressure (CVP)
Systemic vascular resistance (SVR)
Pulmonary vascular resistance (PVR)
Pulmonary artery wedge pressure (PAWP)
A 78-kg patient in septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. After initial fluid volume resuscitation, the patient‘s urine output has been 30 mL/hr for the past 3 hours. Which intervention prescribed by the health care provider would the nurse question?
Administer furosemide (Lasix) 40 mg IV.
Increase normal saline infusion to 250 mL/hr
Give hydrocortisone (Solu-Cortef) 100 mg IV.
Use norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg.
A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention prescribed by the health care provider would the nurse question?
Elevate head of bed to 30 degrees.
Infuse normal saline at 250 mL/hr.
Hold nitroprusside if systolic BP is less than 90 mm Hg.
Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse would be consistent with a diagnosis of neurogenic shock?
Inspiratory crackles
Heart rate 45 beats/min
Cool, clammy extremities
Temperature 101.2F (38.4C)
An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention would the nurse anticipate?
Increase the rate for the dopamine infusion.
Decrease the rate for the nitroglycerin infusion.
Increase the rate for the sodium nitroprusside infusion.
Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.
After a patient who has septic shock receives 2 L of IV normal saline, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. Which medication would the nurse anticipate being prescribed?
Furosemide
Nitroglycerin
Norepinephrine
Sodium nitroprusside
A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is high, and cardiac output is low. Which treatment would the nurse expect to be prescribed?
Furosemide
Hydrocortisone
Epinephrine drip
5% albumin infusion
The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. Which item would the nurse obtain in preparation for the patient‘s arrival?
A dopamine infusion
A hypothermia blanket
Lactated Ringer‘s solution
A 16-gauge IV catheter
Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?
There are no signs of hemorrhage.
Hemoglobin is within normal limits.
Urine output 65 mL over the past hour.
Mean arterial pressure (MAP) is 72 mm Hg.
Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?
The patient is receiving low dose dopamine.
The patient‘s central venous pressure is 3 mmHg.
The patient is in sinus tachycardia at 120 beats/min.
The patient has had no urine output since admission.
Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective?
Heart rate
Orientation
Blood pressure
Oxygen saturation
A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider would the nurse implement first?
Acetaminophen (Tylenol) 650 mg rectally.
Administer normal saline IV at 500 mL/hr.
Start norepinephrine to keep blood pressure above 90 mm Hg.
Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?
Skin cool and clammy
Heart rate of 118 beats/min
Blood pressure of 92/56 mm Hg
O2 saturation of 93% on room air
A patient is admitted to the emergency department (ED) in shock of unknown etiology. Which action would the nurse take first?
Obtain the blood pressure.
Check the level of orientation.
Administer supplemental oxygen.
Obtain a 12-lead electrocardiogram.
A patient has been admitted with dehydration and hypotension after 4 days of vomiting and diarrhea. Which finding is most important for the nurse to report to the health care provider?
New onset of confusion
Decreased bowel sounds
Heart rate 112 beats/min
Pale, cool, and dry extremities
A patient who has neurogenic shock is receiving phenylephrine through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?
The patient‘s heart rate is 58 beats/min.
The patient‘s extremities are warm and dry.
The patient‘s IV infusion site is cool and pale.
The patient‘s urine output is 28 mL over the past hour.
Several interventions are prescribed by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which action will the nurse complete first?
Give diphenhydramine.
Administer epinephrine.
Start continuous ECG monitoring.
Draw blood for complete blood count (CBC).
Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to contact the health care provider?
The patient‘s urine output is 18 mL/hr.
The patient‘s peripheral pulses are weak.
The patient reports diffuse chest pressure.
The patient‘s heart rate is 110 beats/minute.
A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take? (Select all that apply.)
Prepare to administer atropine IV.
Obtain baseline body temperature.
Infuse large volumes of lactated Ringer‘s solution.
Provide high-flow O (100%) by nonrebreather mask.
Prepare for emergent intubation and mechanical ventilation.
Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? (Select all that apply.)
Ambulate postoperative patients as soon as possible after surgery.
Use aseptic technique when manipulating invasive lines or devices.
Remove indwelling urinary catheters as soon as possible after surgery.
Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
Advocate for parenteral nutrition for patients who cannot eat adequate calories.
