Burn Final Exam Questions
1). Burn injuries typically result from energy transfer from various heat sources to the body. These sources include:
Rationale: A burn injury usually results from energy transfer from a heat source to the body. The heat source may be thermal, chemical, or electrical. Exposure to ionizing radiation can also cause burns.
2). High- voltage electric entry wound are _________ in appearance, whereas exit wounds are more likely to _________ as the charge exits.
Rationale: High-voltage current is concentrated at its entrance to the body, then diverges centrally, and finally converges before exiting. The most severe damage to tissue occurs at the sites of contact and exit.
3). A patient who presents with a third degree burn covering the anterior trunk and both right upper and lower extremities would be said to have what percentage of total body surface area burned?
Rationale: According to the Rule of Nines, the anterior trunk equates to 18%, each leg 18%, and each arm 9%. See page 443 in the text for more information.
4). Which is an example of a moderate or uncomplicated burn injury?
Rationale: See chart within the text on page 444
5) The nurse knows that the leading cause of death within the first 24 hours after a burn injury is:
Rationale: see page 444 under Inhalation Injury.
6). Which method is the most accurate way to assess whether a patient with carbon monoxide toxicity is responding to oxygen therapy?
Rationale: see page 446 under carbon monoxide toxicity. Pulse oximetry is unable to distinguish oxygen from carbon monoxide in hemoglobin.
7) A patient was severely burned in a house fire 6 days ago. The nurse suspects that the patient has an infection after discovering which assessment finding:
Rationale: see page 446. Diagnosing infection in a burn patient is difficult because most of these patients already have an elevated core body temperature and white blood cell count. Therefore, glucose in the urine is a much better sign of infection in a burn patient, especially in the presence of a normal blood glucose level.
8). A patient arrives at the emergency department with an electrical burn. The nurse conducts the the secondary assessment. What questions should the nurse ask in determining the possible severity of the burn injury? Select all that apply.
Answer: B, C
9). A nurse sees a teenager get struck by lightning during a thunderstorm on a golf course. What should be the FIRST action by the nurse?
10). A 70-year-old patient has experienced a sunburn over much of the body. What self-care treatment measure is MOST important to emphasize to an older adult in dealing with the effects of the sunburn?
11). A patient receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter. When evaluating the patient's intake and output, which of the following should be taken into consideration?
12). When evaluating the laboratory values of the burn-injured patient, which of the following can be anticipated?
1) In a critically ill patient, what would be the preferred method of blood glucose measurement?
a) venous line
b) arterial line
c) central line
d) all of the above
Rationale: The preferred method of blood glucose measurement in the critically ill patient is through venous lines, central lines or arterial lines over fingerstick glucose testing because often times tissue perfusion is impaired in the critically ill.
2) Jerry is a 17 year old male who has been diagnosed with DKA. Which lab values would you expect the nurse to monitor? (select all that apply)
a) urine ketones
b) serum ketones
Rationale: Urine ketones are positive in DKA. Serum ketones and glucagon are elevated in DKA. ADH is monitored in patients who have SIADH or DI.
a) “I have a hemoglobin A1C of 11 so I won’t be needing any treatment for diabetes”
b) “The hemoglobin A1C gives a good idea of what my blood sugars have been over the past three to four months”
c) “My A1C level will tell me what my blood sugars have been for the last couple of days”
d) “My hemoglobin A1C is 5% which means I will need to start treatment for diabetes”
Rationale: A patient with a hemoglobin A1C level of above 7% should begin treatment. The hemoglobin A1C measures blood glucose levels over three to four months (the life span of a red blood cell is 100-120 days).
4. A 23 year old female with type 1 diabetes mellitus came into the emergency room after becoming increasingly ill. The nurse suspects DKA and knows that this diabetic emergency is precipitated by which of the following: (select all that apply)
Rationale: infection, usually UTI and pneumonia, is the most common precipitating factor of DKA. THe infection provokes the release of counterregulatory hormones that cause hyperglycemia. Other precipitating factors can include stroke, MI, pancreatitis, alcohol or drug abuse, trauma, or a discontinuation of of insulin therapy.
5. DKA is characterized by which of the following signs/symptoms: (select all that apply)
Rationale: hypoglycemia can be a result of increased insulin administration, skipped meals, or excessive exercise. DKA has hyperglycemia as a result of low or no insulin.
6. A patient is being started on an insulin infusion. Prior to beginning this infusion, which should the nurse assess first?
Rationale: potassium levels should be assessed prior to insulin therapy because insulin will push potassium back into the cell, lowering serum potassium.
7. A patient in DKA is on an insulin infusion. Which of the following should be done when the patient’s blood glucose level has reached 250 mg/dl?
Rationale: D5W is added to prevent a precipitous decline in the blood glucose level.
8. A nineteen year old female comes into the ED with a blood glucose reading of 49 mg/dL. She is alert and oriented and responds to all of your questions. What should you expect from the physician?
Rationale: For a conscious adult liquid carbs PO is the best and quickest method of absorption. 15 grams of carbs will raise blood glucose 20-120mg/dL; so start with 15 grams and then recheck glucose levels in 15 minutes.
9. A diabetic patient is admitted with CKD. Upon discharge you chose to provide some education regarding management of the disease. Which topics should you cover? Select all that apply.
Rationale: Goals of diabetic patients with CKD include managing HTN (ACE inhibitors), managing glucose levels to prevent further damage to kidneys, and a low sodium, low protein diet. High potassium diets should be avoided as damaged kidneys may already have difficulties managing electrolytes.
10. A diabetic patient is admitted to your floor for acute renal failure. What lab results is the most important to monitor?
Rationale: In acute renal failure the biggest complications are fluid and electrolyte imbalances. The most important to monitor for is potassium as high levels of potassium can lead to cardiac arrhythmias.
Answer: B: Clients with COPD retain CO2 and the respiratory drive is stimulated when PO2 decreases. Thus, HR, RR, and BP should be evaluated to determine if the client is hemodynamically stable. Symptoms such as dyspnea should also be assessed. A is not the correct answer because oxygen should be titrated up slowly. D is not the correct answer because the patient is not exhibiting signs of respiratory distress requiring intubation.
Answer: B. Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
5. A male client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannula. The client’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client’s respiratory status. Which complication may arise if the client receives a high oxygen concentration?
Answer: A. Rationale: Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don’t cause metabolic acidosis.
6. For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
Answer: C. Rationale: The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler’s position and should not receive sedatives or other drugs that may further depress the respiratory center.
7. Which of the following are significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
Answer: A, C, E; Rationale: A respiratory assessment, which includes auscultating breath sounds and assessing the color of nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the client with pneumonia.
8. Which of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?
9. Which of the following complications is associated with mechanical ventilation?
10. A client has the following arterial blood gas values: pH, 7.52; PaO2: 50 mm Hg, PaCO2: 22 mm Hg; HCO3: 24 mEq/L. The nurse determines that which of the following is a possible cause for these findings?
a. Chronic Obstructive Respiratory Disease (COPD)
b. Diabetic Ketoacidosis with Kussmaul’s respirations
c. Myocardial infarction
d. Pulmonary embolus
Answer: D; A PaCO2 of 28 mm Hg and PaO2 of 50 mm Hg are both abnormal; the PaO2 of 50 mm Hg signifies acute respiratory failure. In evaluating possible causes for this disorder, the nurse should consider conditions that lead to hypoxia and hyperventilation, such as pulmonary embolus. COPD is typically associated with respiratory acidosis and elevated PaCO2. The client with diabetic ketoacidosis most often has metabolic acidosis. A myocardial infarction does not often cause an acid-base imbalance because the primary problem is cardiac in origin.
Cardiovascular Final Exam Questions
1. An older adult client has chest pain and shortness of breath. The healthcare provider prescribes nitroglycerin tablets. What should the nurse instruct the client to do?
A. Put the tablet under the tongue until it is absorbed.
B. Swallow the tablet with 120ml of water.
C. Chew the tablet until it is dissolved.
D. Place the tablet between the cheek and gums until it disappears.
The client is having symptoms of a myocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The client should place the tablet under the tongue and wait until it is absorbed Nitroglycerin tablets are not effective if chewed, swallowed, or placed between the cheek and gums.
2. A 60-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2mg of morphine sulfate given IV. The nurse should first:
A. Administer the morphine.
B. Obtain a 12-lead ECG.
C. Obtain the blood work.
D. Prescribe the chest radiograph.
Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.
3. Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction?
A. Liquids as desired.
B. Small, easily digested meals.
C. Three regular meals per day.
D. Nothing by mouth.
Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.
4. A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
Nursing management for a client with a MI should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.
5. The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include:
Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure. Increased myocardial contractility would be a goal, not decreased contractility.
6. A client has a history of heart failure and has been taking furosemide (Lasix), digoxin (Lanoxin), and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which of the following?
Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client’s history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.
7. Most patients who present with Hypertensive Crisis are very ill and require immediate attention. The most appropriate intervention is administering IV medication to lower blood pressure keeping in consideration that the goal is to:
The goal is to reduce the mean blood pressure by no more than 25% within one hour of starting treatment to avoid hypoperfusion and to prevent or reverse target organ damage.
8. Which of the following IV medications are not used in the treatment of Hypertensive Emergencies?
Norepinephrine stimulates alpha receptors to cause peripheral vasoconstriction and systemic vascular resistance increasing blood pressure.
9. The most important long term goal for a client with hypertension is to:
Compliance is the most important element of hypertension. In most cases, hypertension requires long term therapy which include medications.
10. A client is scheduled for cardiac catheterization. The nurse should do which of the following pre-procedure tasks? Select all that apply.
Answer: B, C, D
For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.
The phlebostatic axis is located at the:
A. Fourth-intercostal space, midaxillary level
B.Sixth-intercostal space, anterior level
C.Second-intercostal space, midaxillary level
D.Third-intercostal space, midaxillary level
Answer: A- Leveling the transducer at the phlebostatic axis is necessary for accurate A-line waveforms and readings.
A nurse notices that his/her patient’s continuous pressure device has deflated to less than 300 mmHg. The nurse should expect to see what type of waveforms:
D.No alterations in the waveforms
The purpose of arterial lines is to (select all that apply):
A.Obtain frequent arterial blood gases
D.Monitor blood pressure continuously
Answer: D- Arterial lines are used to monitor blood pressure continuously and accurately. Blood can also be drawn from this line, but frequent ABGs would not be appropriate without a rationale. Medications are not to be administered through this line, and CVP is not recorded.
A client has a systemic arterial blood pressure monitor. Which of the following should be included in the plan of care for this client?
A.Administer fluids through this access device
B.Monitor the site for infection
C.If tubing becomes kinked, take a routine BP using cuff method
D.Monitor circulation proximal to the insertion site
The nurse knows that pulmonary artery pressure monitoring measures the pressures in the: (select all that apply)
Answers: A, C, D
The nurse has just measured a client’s cardiac output using the thermodilution method. The findings show a notched, uneven curve.
What should the nurse do with these results?
A.Document the finding as a high cardiac output
B.Document the finding as a low cardiac output
C.Repeat the measurement
D.Nothing. There is nothing wrong with the reading
Answer: C: Repeat the measure. A small curve indicates a high CO, a large curve indicates a low CO, and a notched or uneven curves indicates poor injection technique and the assessment should be repeated.
To demonstrate an understanding of the concept of afterload, the nurse identifies which of the following patients as having increased afterload?
A.A hypothermic post-op coronary artery bypass surgical patient
B.A post-op carotid endarterectomy patient on nitroprusside
C.A patient presenting in the early stages of septic shock
D.A patient with chest pain who is receiving IV nitroglycerin
Answer: A- Hypothermia causes vasoconstriction, which leads to increased afterload. B,C, and D are all patient scenarios in which the patient is experiencing vasodilation, which leads to decreased afterload
The critical care nurse is concerned about increased oxygen demand for which of the following patients? (select all that apply)
A.Critically ill post-op patient who is shivering
B.Patient who has indications of developing septic shock
C.Patient who had percutaneous transluminal coronary angioplasty
D.Newly admitted multiple trauma patient
Answer: A, B, D- All these patients have conditions in which the body is consuming oxygen at a higher than normal rate.
Shock and MODS
2) A patient who has recovered from cardiogenic shock asks how this condition develops. The nurse’s best response includes that cardiogenic shock develops:
3) You have just conducted an initial assessment of a patient transferred to the ICU after the development of cardiogenic shock. Which of the following is not an expected sign of this condition?
4) Which of the following are considered criteria for Systemic Inflammatory Response Syndrome? Select all that apply.
Rationale: Although criteria for SIRS and sepsis are similar, culture documented infection is what differentiates sepsis from SIRS.
5) Compensatory mechanisms in response to shock states result in
6) Which of the following is not a common pathophysiological manifestation seen in patients with hypovolemic shock?
a. Altered mentation
b. Rapid and deep respirations
c. Cool and clammy skin
7)Which of the following patients meets the criteria to have MODS?
a. A 65-year-old man with chronic obstructive pulmonary disease (COPD) who requires mechanical ventilation and enteral tube feedings
b. A 42-year-old woman with end-stage renal disease who requires hemodialysis every day
c. A 28-year-old man with septic shock who requires continuous renal replacement therapy and mechanical ventilation
d. A 70-year-old man with diabetes who recently had coronary artery bypass surgery
8) Which of the following are risk factors for septic shock?
A. Advanced Age
B. Very young age
C. Multiple Organ Failure
D. Indwelling Medical Devices
Rationale: All are risk factors for septic shock.
9) Which of the following is not associated with sepsis?
Rationale: Hypotension, not hypertension is associated with sepsis.
Trauma Test Question
1. A 45-year-old man presents to the trauma resuscitation unit after a gunshot wound to the abdomen. He has a temperature of 93ºF and a pH of 7.15. What is the third condition that may be a sign of death in the trauma patient?
C. The triad of complications for trauma patients includes acidosis, hypothermia, and coagulopathy.
2. A woman arrives in the critical care unit after a 30-foot fall. Initial computed tomography scans reveal multiple orthopedic fractures, including a right humerus fracture, pelvic fracture, and bilateral calcaneus fractures. The patient’s chart mentions no other injuries. After assessing the patient, the nurse finds her to be short of breath. After listening to breath sounds, the nurse thinks bowel sounds can be heard in the patient’s chest. What is the next step?
a. Call the physician.
b. Order an immediate chest radiograph.
c. Continue to monitor the patient.
d. Do nothing.
B. A chest radiograph helps in the diagnosis of diaphragm rupture because it shows the abdominal contents of the chest tube.
3. A man arrives in the critical care unit after an exploratory laparotomy to stop hemorrhaging. What is the next step?
a. Monitor the patient’s vital signs and watch for postoperative bleeding.
b. Explain the procedure to the patient and family.
c. Watch for signs of postoperative infection.
d. Continue to resuscitate the patient and continuously monitor the patient for hypothermia, acidosis, and coagulopathy.
D. Many patients who go to the operating room emergently for a damage control procedure do not have a
complete workup and still need resuscitation. Risk factors are hypothermia, acidosis, and coagulopathy.
4. A man involved in a motor vehicle crash with multiple injuries has been in the critical care unit for approximately 2 weeks. When doing the morning assessment, the nurse notes that the patient’s oxygenation requirement has increased, that he needs more ventilator support, and that his oxygen saturation is decreasing. What complication with this patient should concern the nurse?
a. Acute respiratory distress syndrome
b. Deep venous thrombosis
c. Pulmonary embolism
d. Fat embolus
A. The respiratory system is the most sensitive and is usually the first to indicate systemic failure.
5. A 21-year-old woman is admitted to the floor after being assaulted. Her injuries are primarily facial. She has Le Fort’s fractures of her face and soft tissue swelling; because her eyes are swollen, she is unable to see. What does the nurse need to provide to this patient?
a. Stimulation (e.g., lights, noise, TV)
b. Contact with a social worker
c. A quiet, safe environment in which the patient feels safe and is able to have her questions answered and concerns addressed
d. Nothing; the patient is conscious and is able to ask for what she needs.
C. Many patients with facial trauma lose some of their senses and need constant reassurance.
6. A 30-year-old man is involved in a motorcycle crash. Barely conscious, he is intubated secondary to a decreased level of consciousness. He reports excruciating hip pain. His blood pressure is 90/50 mm Hg, and as his primary survey is completed, his blood pressure is decreasing and his heart rate is increasing without any obvious signs of bleeding. Initial films show an LCIII pelvic fracture. What is the next step?
a. Continue to monitor the patient because there are no obvious signs of bleeding.
b. Call orthopedics immediately and notify the operating room of a potential orthopedic surgery.
c. Call the pain team to adequately medicate this patient for his hip pain.
d. Increase IV fluid to attempt to correct his blood pressure.
B. An open pelvic fracture is an orthopedic emergency that needs emergent stabilization.
7. A male comes into the ER exhibiting a penetrating knife wound. When assessing the injury the trauma nurse knows that penetrating injury is (select all that apply)
A, C, D
8. A 18 year old female is admitted following of a fractured tibia and cast application. Which nursing assessment should be reported to the physician? Select all that apply.
9. A client is hospitalized for open reduction of a fractured femur. During postoperative assessment, the nurse monitors for signs and symptoms of fat embolism, which include:
a. pallor and coolness of the affected leg.
b. nausea and vomiting after eating.
c. hypothermia and bradycardia.
d. altered mental status and petechiae.
10. A 68 year old male presents to the ER with a stab wound to the left upper quadrant with peritoneal signs. Skin: Pale, cool,moist. 90/58, 110. CT is out of order. Your next move:
11. A 48 year old female patient is brought in to the ER by paramedics after a MVA. The patient complains of severe chest pain and the nurse notes paradoxical breathing on the right side. What secondary conditions should the nurse be monitoring for? Select all that apply.
A. C. E. Paradoxical breathing is indicative of flail chest and rib fx which are commonly associated with lung injury either from the force of the impact being great enough to break lungs also can cause underlying tissue damage (ruptured bronchi and pulmonary contusion) or from a broken rib puncturing the lung underneath (pneumothorax).
12. You are a nurse working in the ICU and are taking report from the ER nurse about an 18 year old male that fell off the roof of a one story house. He sustained multiple fractures including right radius and ulna and the 4th and 5th right ribs. A chest tube was placed an hour ago on the right side in the ER to drain a hemothorax that occurred secondary to the rib fractures. The ER nurse reports about 300 mL of sanguineous drainage from the chest tube since placement. After finishing bedside report, you begin your initial assessment and check the chest tube noting sanguineous drainage of 210 mL in the collection device. What is your priority intervention?
B. Notify the physician. Drainage of more than 200 mL/hr for 2 consecutive hours may indicate a significant injury and the need for further follow-up.
13. A 16 year old female cheerleader presents to the ER after falling from the top of a stunt landing face down on the track at the football game approximately 6 hrs ago. The patient is complaining of chest pain that gets worse with inspiration. Upon assessment, you find a BP of 85/58, HR 140, shallow and rapid breaths, muffled heart sounds, distended neck veins, weak peripheral pulses, and pulsus paradoxus. Based off the patient’s history and assessment findings what condition should the triage nurse suspect?
D. Cardiac tamponade: associated with blunt trauma, injury to the pericardial space allows blood to fill the space and compresses the heart leading to Beck’s triad (decreased blood pressure, muffled heart sounds, and distended neck veins) and pulsus paradoxus.
answer: a, d
answer: b, d, e
GI Bleed and Hematological Disorders
“c”: decreased hematocrit
2. Which of the following interventions is considered to be part of the initial treatment of upper GI bleeds?
B. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
C. Administration of an enema to clear the GI tract
D. Fluid resuscitation
“d”: fluid resuscitation
3. Upon assessment the nurse observes the stool of a patient with a GI bleed and notices that the stool has fresh bright red blood, this finding is known as:
D. Mallory- Weiss tear
4. A lower GI bleed can involve: (select all that apply)
“a, b, & d”: rectum, jejunum, and ileum
5. Sepsis is the most common cause of DIC. All the following statements concerning this life-threatening complication is true except:
a.) The rapidity of onset is determined by the intensity of the trigger and is related to the condition of the patient’s liver, bone marrow and endothelium.
b.) In the early phase, the patient may demonstrate manifestations of thrombosis and microemboli.
c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock.
d.) The most critical intervention for DIC is the early identification and treatment of the underlying disorder.
“c” Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock
6. What laboratory values would you expect to see in a patient with disseminated intravascular coagulation (DIC)?
a.) Increased fibrinogen; increased platelets
b.) Decreased fibrinogen; decreased platelets
c.) Decreased fibrinogen; no change in platelets
d.) No change in fibrinogen; decreased platelets
“b” Decreased fibrinogen; decreased platelets
7. The nurse is administering oral care on a client with disseminated intravascular coagulopathy (DIC). Which if the following is the most appropriate for this client?
a.) Flossing should be limited to once a day.
b.) Alcohol-based mouthwashes should be used to prevent infection.
c.) Oral swabs should be used in administering oral care.
d.) Tooth brushing should be limited to once a shift.
“c” Oral swabs should be used in administering oral care.
8. The hallmark of HIT is a decrease in platelet count to less than ___ of baseline.
9. HIT is characterized by which of the following?
b) hearing loss
c) immune dysfunction
10. What is the main treatment for HIT?
a) blood transfusion
b) FFP transfusion
c) stopping heparin therapy
c, stopping heparin therapy
A nurse at an outpatient clinic is providing education regarding CKD to a patient. The nurse recognizes the patient has understood the teaching when he states:
A. “I need to control my high blood pressure as the leading cause of kidney disease is hypertension.”
B. “If I continue to take my medication as prescribed my kidney function can resume back to normal.”
C. “Although I realize i have chronic kidney disease, it is still important I follow the medication regimen.”
D. “Kidney failure is defined as a GFR of 30 or less.”
A new grad nurse is being oriented to a unit. She recognizes that as a nurse caring for a CKD patient involves all of the following (select all that apply.)
A. Managing fluid balance
B. Managing acid-base alterations
C. Providing psychosocial support
D. Monitoring for changes on the telemetry monitor
The nurse is caring for a patient in the ICU who is no longer tolerating hemodialysis due to hypotension and has been ordered to receive CRRT. Which of the following statements best describes the difference between hemodialysis and CRRT?
A. CRRT is a long-term therapy that can be continued as an outpatient, whereas hemodialysis is for inpatients only.
B. Hemodialysis is reserved for hemodynamically stable patients, whereas CRRT is best for patients with potential hemodynamic instability.
C. The patient’s mean arterial pressure drives blood through the hemodialysis filter.
D. CRRT requires placement of an arteriovenous fistula.
A patient returns to the ICU following placement of a new peritoneal dialysis catheter. When performing peritoneal dialysis, the nurse understands that with this type of dialysis, the semipermeable membrane is the:
A. Abdominal contents
B. Filter in the tubing
are unable to raise their eyebrows?
3. After returning from the OR, a patient has vitals of 98.9 F, 112/68, 12 RR, 97% on 2 L, 81 BPM, pain rating 5 out of 10 and pinpoint pupils, what interventions should the nurse complete?
a. Administer narcan & increase O2 therapy
b. Administer IV morphine
c. Increase O2 therapy
d. Continue to monitor the patient
4. Treatment for increased intracranial pressure (ICP) is initiated when ICP reaches:
a. 15 mm Hg
b. 18 mm Hg
c. 20 mm Hg
d. 25 mm Hg
5. Cushing’s triad is a set of clinical manifestations that occur together and indicate increased intracranial pressure (ICP). Which of the following is not included in this triad?
c. Increased systolic blood pressure
d. Widened pulse pressure
6. A patient presents with rhinorrhea of thin fluids. When dabbing the drainage, the nurse notes a layer of fluids, with blood on the inside and a yellowish ring on the outside. The nurse should:
a. Insert an NG tube to prevent aspiration
b. Pack the nose with gauze until drainage decreases
c. Prep the patient for surgery
d. Instruct the patient not to blow his/her nose
7. Which of the following diagnostics can help identify the diagnosis of stroke? Select all that apply.
a. Diffuse-weighted imaging (DWI)
b. CT scan
c. Cerebral angiography
d. Magnetic resonance angiogram (MRA)
8. During assessment, a patient with spinal cord injury presents with a flushed face, pupil dilation, blurred vision, throbbing headache, bradycardia, and nausea. What type of autonomic dysfunction is the patient experiencing?
a. Autonomic dysreflexia
b. Spinal shock
c. Neurogenic shock
d. Orthostatic hypotension
9. Motor vehicle crashes most commonly cause which type(s) of spinal cord injuries? Select all that apply.
a. Hyperflexion injuries
b. Hyperextension injuries
c. Axial loading injuries
d. Rotational injuries
10. Which of the following correctly characterizes the neurologic dysfunction associated with Brown-Sequard cord syndrome?
a. Complete motor paralysis and loss of pain and temperature below the level of injury
b. Ipsilaterally, the patient has loss of pain, temperature, and touch, but maintains motor function
c. Ipsilaterally, the patient has complete motor paralysis but maintains sensation of pain, temperature, and touch
d. Contralaterally, the patient has complete motor paralysis but maintains sensation of pain, temperature, and touchC. Peritoneal lining
D. Renal lining
Uremic patients with CKD present with all of the following except?
B. Ammonia on the breath
C. Decreased baseline temperature
Which of the following is a potential side effect of rHuEPO?
A. Increased bleeding
B. Increased blood pressure
C. Muscle cramps
Nervous System & Neurological Disorders