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?

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?

During the emergent phase of burn care, which assessment is most useful in determining whether the patient is receiving adequate fluids?

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?

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?

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?

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?

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention would the nurse implement first?

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?

Which patient would the nurse assess first?

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?

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?

Which nursing action is a priority for a patient who had a burn injury while working on an electrical power line?

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).

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).

When a nurse is performing a primary survey in the ED, what is being assessed?

During the primary survey, the nurse observes asymmetric chest wall movement. What intervention would the nurse do first?

During the secondary survey of a trauma patient in the ED, why is it important that the nurse obtain details of the incident?

What nursing intervention is done during the “E” step of the primary survey?

When is the placement of a nasogastric tube contraindicated during emergency care?

In assessing the emergency patient’s health history, what information is obtained using the mnemonic SAMPLE?

What heat-related emergency would the healthy athlete with inadequate fluid intake be most likely to experience after exercise?

Which statements describe heat exhaustion? Select all that apply.

What is the first priority in managing the patient after drowning?

The patient is admitted with severe acidosis after trying to commit suicide by ingesting aspirin. What would be used to treat this patient?

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?

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?

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 the nurse to take during the observation period?

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?

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?

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient requires the most immediate treatment?

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?

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?

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?

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?

Which interventions will the nurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.)

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.)

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 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?

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?

After change-of-shift report in the progressive care unit, for which patient would the nurse provide care first?

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?

Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient‘s left ventricular afterload?

After surgery for an abdominal aortic aneurysm, a patient‘s central venous pressure (CVP) monitor indicates low pressures. Which action would the nurse take?

When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment?

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?

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?

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?

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?

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?

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?

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?

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?

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?

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?

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective?

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?

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?

A patient is admitted to the emergency department (ED) in shock of unknown etiology. Which action would the nurse take first?

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?

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?

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.)

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.)

Which assessment finding would the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30?

The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. Which aim will be the primary treatment goal?

A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse‘s teaching about management of CKD has been effective?

Which information will the nurse monitor to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?

Sodium polystyrene sulfonate (Kayexalate) is prescribed to be given via nasogastric tube for a patient with hyperkalemia. Which assessment would the nurse make before administering the medication?

Which laboratory result would the nurse check before administering calcium carbonate to a patient with chronic kidney disease?

A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft?

Which action will the nurse include in the plan of care to maintain the patency of a patient‘s left arm arteriovenous fistula?

A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching?

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?

Which information in a patient‘s history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation?

Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid taken for four years after kidney transplantation?

A patient who had a kidney transplant eight years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone. Which assessment data will be of most concern to the nurse?

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication being taken by the patient indicates a need for patient teaching?

What laboratory value would the nurse check before administering captopril to a patient with stage 2 chronic kidney disease?

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin. Which laboratory value would the nurse monitor for adverse effects of the medication?

A patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information would the nurse discuss with the health care provider before giving the medication?

Which intervention will be included in the plan of care for a patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein?

A patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider?

A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy would the nurse implement first?

A patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action would the nurse take first?

A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to a dialysis technician?

A licensed practical/vocational nurse (LPN/VN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention?

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider?

During routine hemodialysis, a patient reports nausea and dizziness. Which action would the nurse take first?

The nurse is titrating the IV fluid infusion rate four hours after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider?

A patient reports leg cramps during hemodialysis. Which action would the nurse take?

After receiving change-of-shift report, which patient would the nurse assess first?

Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis? (Select all that apply.)

The nurse is caring for an unresponsive terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action would the nurse take?

The nurse is caring for a client experiencing  hypovolemia. Which action will support an increased preload and improve cardiac output?

The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). Which factor contributes to fluid retention during mechanical ventilation?

• An older adult client with severe dehydration is admitted to the intensive care unit (ICU) after being found unconscious on the floor of the home. Laboratory results include:

  ---

  sodium 122 mEq/L

  • hematocrit 56%

  • blood urea nitrogen (BUN) 38 mg/dL

  ---

  The provider orders intravenous administration of D5W at 200 ml/hour to treat hypovolemia. Several hours after the infusion is started, the client has a generalized seizure. Which statement most accurately describes the cause of the seizure?

A medication given as a replacement for ADH is __________.

• The nurse obtains hemodynamic measurements, which reveal:

  • **** central venous pressure (CVP) 9 mmHg

  • **** pulmonary artery wedge pressure (PAWP) 17 mmHg

  ---

  Which findings should the nurse anticipate? Select all that apply.

Continuous renal replacement therapy (CRRT) is often preferred for critically ill clients with fluid volume overload. Why is CRRT preferred over intermittent hemodialysis (IHD)?

Recognizing Cues: Assessment Findings in Fluid Balance Alterations: At 1300, a 72-year-old man is admitted to the intensive care unit (ICU) with a diagnosis of congestive heart failure. After assessing the client, the nurse finds dyspnea, bilateral lower lobe crackles, and a urinary output of 28 mL in the past hour. The client is anxious and restless.

Assessment findings indicate that the client is in _____(1)_____. The nurse determines that the most likely diagnosis is  _____(2)_____ due to _____(3)_____. The client’s confusion and restlessness are caused by decreased _____(4)_____. Decreased urinary output indicates  ____(5)______ due to  cardiac output ____(6)______.

At 1400, the client’s dyspnea has worsened and urine output is 20 ml for the past hour. A pulmonary artery catheter is inserted for hemodynamic monitoring. Based on the client’s history, which readings does the nurse anticipate? Select all that apply.

Based on the correct interpretation of hemodynamic parameters, which provider prescriptions does the nurse anticipate? Select all that apply.

The client’s condition continues to decline. Continuous renal replacement therapy (CRRT) is prescribed. Which statement indicates a correct understanding of why CRRT was prescribed instead of hemodialysis?

A nurse is triaging four clients in the emergency department (ED). Which client is most at risk of developing obstructive shock?

A nurse in the emergency department (ED) is caring for a client who was recently stung by a bee. Which findings are clinical manifestations of anaphylactic shock? Select all that apply.

The nurse is caring for a client who has a prescription for intravenous dobutamine. Which type of shock is treated by this medication?

As hypovolemia progresses, the body attempts to compensate for intravascular volume loss. Which findings are the early signs of hypovolemic shock due to compensatory efforts? Select all that apply.

A nurse is receiving report on five clients. After careful review, which clients must be closely monitored for acute kidney injury (AKI)? Select all that apply.

^{There are three types of acute kidney injury (AKI): prerenal, intrarenal, and postrenal. Match the incident to the cause of AKI.}

(1) = Examples include renal vein/artery stenosis & hypotension (volume depletion, decreased cardiac output).

(2) = Examples include overuse of non-steroidal anti-inflammatory drugs (NSAIDs), direct damage from trauma, nephrotoxins, or glomerulonephritis.

(3) = Examples include benign prostatic hyperplasia (BPH), renal stones, and spinal cord injury.

The nurse is caring for a client with acute kidney injury. The provider prescribes continuous renal replacement therapy (CRRT). What is the most common indication for using CRRT?

Which are intrarenal causes of acute kidney injury (AKI)? Select all that apply.

The nurse is caring for a client at risk for acute kidney injury. Which diagnostic studies are used to stage acute kidney injury (AKI)?

The nurse is caring for a client in the oliguric phase of acute kidney injury (AKI). Select the assessment findings the nurse anticipates.

The nurse is preparing to initiate hemodialysis for a client with acute kidney injury secondary to hypovolemia. Select three priority nursing actions.

A temporary vascular device is placed for immediate use for a client with acute kidney injury who requires hemodialysis. During hemodialysis, what is the nurse's priority assessment?

A nurse is caring for a client who is to have a line placed for hemodynamic monitoring. Which statement by the nurse indicates an understanding of the procedure?