Nursing Care for Patients with Respiratory Diseases, Exams of Nursing

Download Nursing Care for Patients with Respiratory Diseases and more Exams Nursing in PDF only on Docsity! Complex Care Final Exam Practice Questions With 100% Correct SOLUTION BEST GRADED A PLUS 2024 LATEST UPDATE The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? a. Teach the patient to cough and deep breathe. b. Take the temperature, pulse, and respiratory rate. c. Obtain a sputum specimen for culture and Gram stain. d. Check the patient's oxygen saturation by pulse oximetry. SOLUTION- c. Obtain a sputum specimen for culture and Gram stain. A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks. The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required? a. "I will be given amphotericin B to treat the fungus." b. "I got this fungus because I am immunocompromised." c. "I need to be isolated from my family and friends so they won't get it." d. "The effectiveness of my therapy can be monitored with fungal serology titers." SOLUTION- c. "I need to be isolated from my family and friends so they won't get it." The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers. A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? a. Lobectomy surgery is usually needed to drain the abscess. b. IV antibiotic therapy will be used for a 6- month period of time. c. Oral antibiotics will be used until there is evidence of improvement. d. Culture and sensitivity tests are needed for 1 year after resolving the abscess SOLUTION- c. Oral antibiotics will be used until there is evidence of improvement. IV antibiotics are used until the patient and radiographs show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation. One week after a thoracotomy, a patient with chest tubes (CTs) to water- seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? a. Water-seal chamber has 5 cm of water. b. No new drainage in collection chamber c. Chest tube with a loose-fitting dressing d. Small pneumothorax at CT insertion site SOLUTION- c. Chest tube with a loose-fitting dressing If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air. During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? a. Pneumococcal b. Staphylococcus aureus c. Haemophilus influenzae d. Bacille-Calmette-Guérin (BCG) SOLUTION- a. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, or living in a long- term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis is prevalent. While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? a. Continue with ambulation. b. Obtain a physician's order for arterial blood gas. c. Obtain a physician's order for supplemental oxygen. d. Move the oximetry probe from the finger to the earlobe SOLUTION- c. Obtain a physician's order for supplemental oxygen. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk. The nurse is caring for a group of patients. Which patient is at risk of aspiration? a. A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery b. A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube d. A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields SOLUTION- c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration. A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? a. Pulmonary infarction b. Pulmonary hypertension c. Cytomegalovirus (CMV) d. Bronchiolitis obliterans (BOS) SOLUTION- d. Bronchiolitis obliterans (BOS) BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant. The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? a. Basilar crackles b. Oxygen saturation of 85% c. Presence of greenish sputum d. Respiratory rate of 28 breaths/min SOLUTION- a. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem but do not definitely support the nursing diagnosis of ineffective airway clearance. The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? a. Cover the chest wound with a nonporous dressing taped on three sides. b. Pack the chest wound with sterile saline soaked gauze and tape securely. c. Stabilize the chest wall with tape and initiate positive pressure ventilation. d. Apply a pressure dressing over the wound to prevent excessive loss of blood. SOLUTION- a. Cover the chest wound with a nonporous dressing taped on three sides. The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing. An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? a. Perform a comprehensive health history with the patient to review prior respiratory problems. b. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. c. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. d. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. SOLUTION- d. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed. The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? a. Hyperresonance on percussion b. Vesicular breath sounds in all lobes c. Increased vocal fremitus on palpation d. Fine crackles in all lobes on auscultation SOLUTION- c. Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area. The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? a. Humidify the oxygen as able. b.Administer cough suppressant q4hr. c. Teach patient to splint the affected area. d. Increase fluid intake to 3 L/day if tolerated. SOLUTION- d. Increase fluid intake to 3 L/day if tolerated. The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? a. The patient has lung cancer. b. The incision will be medial sternal or lateral. c. Chest tubes will not be needed postoperatively. d. Less discomfort and faster return to normal activity SOLUTION- d. Less discomfort and faster return to normal activity The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS. A patient with a persistent cough is diagnosed with pertussis. What treatment does the nurse anticipate administering to this patient? a.Antibiotic b. Corticosteroi d c. Bronchodilator d. Cough suppressant SOLUTION- a. Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordetella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis. The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? a. Obesity b. Pneumoni a c. Malignancy d. Cigarette smoking e. Prolonged air travel SOLUTION- a. Obesity c. Malignancy d. Cigarette smoking e. Prolonged air travel An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders. After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? a. Orthostatic blood pressures b. Sputum culture and sensitivity c. Pulmonary function evaluation d. Serum laboratory studies ordered for AM SOLUTION- b. Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics. The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequela? a. Pulmonary embolism b. Pulmonary hypertension c. Post- thrombotic syndrome d. Venous thromboembolism SOLUTION- d. Venous thromboembolism The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and postthrombotic syndrome are the sequelae of venous thromboembolism. The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? a. Hematocrit (Hct) b. Hemoglobin (Hgb) c. Prothrombin time (PT) d. Partial thromboplastin time (PTT) SOLUTION- c. Prothrombin time (PT) Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the PT or the international normalized ratio demonstrate the need for this medication. When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? a. Duplex ultrasound b. Contrast venography c. Magnetic resonance venography d. Computed tomography venography SOLUTION- a. Duplex ultrasound The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed A 62-yr-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker with a history of gout. To prevent complications, which factor is priority in patient teaching? a. Gender b. Smoking c. Ethnicity d. Comorbidities SOLUTION- b. Smoking Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore, tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD. A 32-yr-old woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the effectiveness of the medication, which assessment will the nurse perform? a. Improved skin turgor b. Decreased cardiac rate c. Improved finger perfusion d. Decreased mean arterial pressure SOLUTION- c. Improved finger perfusion Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved, and vasospastic attacks are reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status. The patient has chronic venous insufficiency and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what patients 'always' have ordered. Which assessment finding would indicate the application of compression stockings could harm the patient? a. Rest pain b. High blood pressure c. Elevated blood sugar d. Dry, itchy, flaky skin SOLUTION- a. Rest pain Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered. The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? a. Decreased cardiac output b. Increased blood pressure c. Cerebral or pulmonary emboli d. Excessive bleeding from incision or IV sites SOLUTION- c. Cerebral or pulmonary emboli Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. When the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium. The nurse is reviewing the laboratory test results for a 68-yr-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. On postoperative day 2, the international normalized ratio (INR) result is 2.7. Which action by the nurse is most appropriate? a. Hold the daily dose of warfarin. b.Administer the daily dose of warfarin. c. Teach the patient signs and symptoms of bleeding. d. Call the physician to request an increased dose of warfarin. SOLUTION- b. Administer the daily dose of warfarin. The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. To maintain therapeutic values, the nurse will administer the medication as ordered. Holding the medication would lower the INR, which would increase the risk of clot formation. Conversely, the higher the INR is, the more prolonged the clotting time. Calling the health care provider is not indicated. Although teaching is important, administering the medication is a higher priority at this time. A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? a. Buttock, upper outer quadrant b.Abdomen, anterior-lateral aspect c. Back of the arm, 2 inches away from a mole d.Anterolateral thigh, with no scar tissue nearby SOLUTION- b. Abdomen, anterior- lateral aspect Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles. A 73-yr-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide teaching on which type of diet for this patient and his caregiver? a. Low-fat diet b. High-protein diet c. Calorie-restricted diet d. High-carbohydrate diet SOLUTION- b. High-protein diet To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines. The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? a. Spread the skin before inserting the needle. b. Leave the air bubble in the prefilled syringe. c. Use the back of the arm as the preferred site. d. Sit the patient at a 30-degree angle before administration. SOLUTION- b. Leave the air bubble in the prefilled syringe. The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue. The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT) who is scheduled for an emergency appendectomy. Vitamin K is ordered for immediate administration. The international normalized ratio (INR) value is 1.0. Which nursing action is most appropriate? a. Administer the medication as ordered. b. Hold the medication and record in the electronic medical record. c. Hold the medication until the lab result is repeated to verify results. d.Administer the medication and seek an increased dose from the health care provider. SOLUTION- b. Hold the medication and record in the electronic medical record. Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore, it may be necessary to give vitamin K before surgery to reduce the risk of hemorrhage. However, the INR value is normal, and vitamin K is not required, so the medication would be held and recorded in the electronic medical record. A 39-yr-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? a. Platelet count b.Activated clotting time (ACT) c. International normalized ratio (INR) d.Activated partial thromboplastin time (APTT) SOLUTION- d. Activated partial thromboplastin time (APTT) Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin. What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? a.Application of topical antibiotics to venous ulcers b. Maintaining the patient's legs in a dependent position c.Administration of oral and/or subcutaneous anticoagulants d.Teaching the patient the correct use of compression stockings SOLUTION- d. Teaching the patient the correct use of compression stockings CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position. A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? a. Paralysis b. Paresthesi a c. Cramping d. Referred pain SOLUTION- b. Paresthesia The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred. Which assessment finding would alert the nurse that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox)? a. Crackles bilaterally in the lung bases b. Pain and swelling in a lower extremity c. Absence of arterial pulse in a lower extremity d. Abdominal pain with decreased bowel sounds SOLUTION- b. Pain and swelling in a lower extremity Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in a lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy. A 67-yr-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? a. Patient complains of chest pain with strenuous activity. b. Patient says muscle leg pain occurs with continued exercise. c. Patient has numbness and tingling of all his toes and both feet. d. Patient states the feet become red if he puts them in a dependent assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it. What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply.)? a. Ramipril (Altace) b. Cilostazol (Pletal) c. Simvastatin (Zocor) d. Clopidogrel (Plavix) e. Warfarin (Coumadin) f. Aspirin (acetylsalicylic acid) SOLUTION- a. Ramipril (Altace) c. Simvastatin (Zocor) f. Aspirin (acetylsalicylic acid) Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent cardiovascular disease events in PAD patients. Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a. A 70-yr-old man with high cholesterol and hypertension b. A 40-yr-old woman with obesity and metabolic syndrome c. A 60-yr-old man with renal insufficiency who is physically inactive d. A 65-yr-old woman with hyperhomocysteinemia and substance abuse SOLUTION- a. A 70-yr-old man with high cholesterol and hypertension The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol. The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient's health history? a. Hypocapnia b. Tachycardia c. Bronchospasm d. Nausea and vomiting SOLUTION- c. Bronchospasm Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β- blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD. The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency. A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After one hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority? a. Start an infusion of 0.9% normal saline at 100 mL/hr. b. Maintain the current administration rate of the nitroprusside. c. Request insertion of an arterial line for accurate blood pressure monitoring. d. Stop the nitroprusside infusion and assess the patient for potential complications. SOLUTION- d. Stop the nitroprusside infusion and assess the patient for potential complications. Nitroprusside is a potent vasodilator medication. A blood pressure of 234/118 mm Hg would have a calculated MAP of 177 mm Hg. Subtracting 25% (or 44 mm Hg) = 133 mm Hg. The initial treatment goal is to decrease MAP by no more than 25% within minutes to 1 hour. For this patient, the goal MAP would be approximately 133 mm Hg. Minimal MAP required to perfuse organs is around 60 to 65 mm Hg. Lowering the blood pressure too rapidly may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. The priority is to stop the nitroprusside infusion and then use fluids only if necessary to support restoration of MAP. When caring for elderly patients with hypertension, which information should the nurse consider when planning care (select all that apply.)? a. Systolic blood pressure increases with aging. b. Blood pressures should be maintained near 120/80 mm Hg. c. White coat syndrome is prevalent in elderly patients. d. Volume depletion contributes to orthostatic hypotension. e. Blood pressure drops 1 hour postprandially in many older patients. f. Older patients will require higher doses of antihypertensive medications. SOLUTION- a. Systolic blood pressure increases with aging. c. White coat syndrome is prevalent in elderly patients. d. Volume depletion contributes to orthostatic hypotension. e. Blood pressure drops 1 hour postprandially in many older patients. Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older patients have significantly higher blood pressure readings when taken by health care providers (white coat syndrome). Older patients experience orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients experience a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability. A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing instruction, which statement by the patient indicates correct understanding? a. "If I take this medication, I will not need to follow a special diet." b. "It is normal to have some swelling in my face while taking this medication." c. "I will need to eat foods such as bananas and potatoes that are high in potassium." d. "If I develop a dry cough while taking this medication, I should notify my doctor." SOLUTION- d. "If I develop a dry cough while taking this medication, I should notify my doctor." Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced- sodium diet. The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next? a. Repeat BP and HR in this position. b. Record the BP and HR measurements. c. Take BP and HR with patient standing. d. Return the patient to the supine position SOLUTION- c. Take BP and HR with patient standing. The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine positon. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes. Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mm Hg. What should the nurse do next? a. Assess his adherence to therapy. b. Ask him to make an exercise plan. c. Instruct him to use the DASH diet. d. Request a prescription for a thiazide diuretic. SOLUTION- a. Assess his Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure- lowering medication. In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? a. Serum uric acid of 3.8 mg/dL b. Serum creatinine of 2.6 mg/dL c. Serum potassium of 3.5 mEq/L b. Blood urea nitrogen of 15 mg/dL SOLUTION- b. Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits. When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse explain? a. Blocks β-adrenergic effects b. Relaxes arterial and venous smooth muscle c. Inhibits conversion of angiotensin I to angiotensin II d. Reduces sympathetic outflow from central nervous system SOLUTION- c. Inhibits conversion of angiotensin I to angiotensin II Lisinopril is an angiotensin-converting enzyme inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II- mediated vasoconstriction and sodium and water retention. β blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central acting α-adrenergic antagonists reduce sympathetic outflow from the central nervous system to produce vasodilation and decreased systemic vascular resistance and blood pressure. When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? a. Broiled fish b. Roasted duck c. Roasted turkey d. Baked chicken breast SOLUTION- b. Roasted duck Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet. The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-yr-old obese female patient admitted with heart failure. Which action by the UAP will require the nurse to intervene? a. Waiting 2 minutes after position changes to take orthostatic pressures b. Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second c. Taking the blood pressure with the patient's arm at the level of the heart disease and increased intracranial pressure. Clubbing of fingers may occur in subacute forms of infective endocarditis and valvular heart disease. The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which finding is significant? a. Regurgitant murmur at the mitral valve area b. Point of maximal impulse palpable in fourth intercostal space c. Heart rate of 94 beats/min and capillary refill time of 2 seconds d. Respiratory rate of 18 breaths/min and heart rate of 90 beats/min SOLUTION- a. Regurgitant murmur at the mitral valve area A regurgitant murmur of the aortic or mitral valves would indicate valvular disease, which is a complication of endocarditis. All the other findings are within normal limits. The nurse is caring for a patient who received a mechanical aortic valve replacement two years ago. Current lab values include an international normalized ratio (INR) of 1.5, platelet count of 150,000/μL, and hemoglobin of 8.6g/dL. Which nursing action is most appropriate? a. Assess the vital signs. b. Start intravenous fluids. c. Monitor for signs of bleeding. d. Report laboratory values to the health care provider. SOLUTION- d. Report laboratory values to the health care provider. Patients with mechanical valve replacement are placed on anticoagulants and should be in a therapeutic INR range of 2.5 to 3.5. Administration of Coumadin (Warfarin) prolongs clotting time and prevents clot formation on the valve. The low INR would require a call to the healthcare provider for an order increase the medication dose. Vital signs would be unchanged related to the low INR. Intravenous fluids are not indicated. The patient is at risk of forming clots, not bleeding. On admission to the emergency department, a patient with cardiomyopathy has an ejection fraction of 10%. On assessment, the nurse notes bilateral crackles and shortness of breath. Which additional assessment finding would most indicate patient decline? a. Increased heart rate b. Increased blood pressure c. Decreased respiratory rate d. Decreased level of consciousness SOLUTION- d. Decreased level of consciousness Decreased level of consciousness indicates a lack of perfusion, hypoxia, or both. A patient with an ejection fraction of 10% indicates very low cardiac output. Bilateral crackles and shortness of breath are consistent with decompensating heart failure. The nurse would expect an increase in heart rate, blood pressure, and respiratory rate in response to the low ejection fraction. When blood pressure drops, the nurse would be aware of potential shock. The nurse provides discharge instructions for a 40-yr-old woman newly diagnosed with cardiomyopathy. Which statement indicates that further teaching is necessary? a. "I will avoid lifting heavy objects." b. "I can drink alcohol in moderation." c. "My family will need to take a CPR course." d. "I will reduce stress by learning guided imagery." SOLUTION- b. "I can drink alcohol in moderation." Patients with cardiomyopathy should avoid alcohol consumption, especially in patients with alcohol-related dilated cardiomyopathy. Avoiding heavy lifting and stress, as well as family members learning CPR, are recommended teaching points. An 80-yr-old patient with uncontrolled type 1 diabetes mellitus is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to do or have what done? a.Aortic valve replacement b.Take nitroglycerin for chest pain. c. Open commissurotomy (valvulotomy) procedure d. Percutaneous transluminal balloon valvuloplasty (PTBV) procedure SOLUTION- d. Percutaneous transluminal balloon valvuloplasty (PTBV) procedure The PTBV procedure is best for this older adult patient who is a poor surgery candidate related to the uncontrolled type 1 diabetes mellitus. Aortic valve replacement would probably not be tolerated well by this patient, although it may be done if the PTBV fails and the diabetes is controlled in the future. Nitroglycerin is used cautiously for chest pain because it can reduce blood pressure and worsen chest pain in patients with aortic stenosis. Open commissurotomy procedure is used for mitral stenosis. A 25-yr-old patient with a group A streptococcal pharyngitis does not want to take the antibiotics prescribed. What should the nurse tell the patient to encourage the patient to take the medications and avoid complications of the infection? a. "The complications of this infection will affect the skin, hair, and balance." b. "You will not feel well if you do not take the medicine and get over this infection." c. "Without treatment, you could get rheumatic fever, which can lead to rheumatic heart disease." d. "You may not want to take the antibiotics for this infection, but you will be sorry if you do not." SOLUTION- c. "Without treatment, you could get rheumatic fever, which can lead to rheumatic heart disease." Rheumatic fever (RF) is not common because of effective use of antibiotics to treat streptococcal infections. Without treatment, RF can occur and lead to rheumatic heart disease, especially in young adults. The complications do not include hair or balance. Saying that the patient will not feel well or that the patient will be sorry if the antibiotics are not taken is threatening to the patient and inappropriate for the nurse to say. The patient had a history of rheumatic fever and has been diagnosed with mitral valve stenosis. The patient is planning to have a biologic valve replacement. What protective mechanisms should the nurse teach the The nurse is teaching a community group about preventing rheumatic fever. What information should the nurse include? a. Prompt recognition and treatment of streptococcal pharyngitis b.Avoidance of respiratory infections in children born with heart defects c. Completion of 4 to 6 weeks of antibiotic therapy for infective endocarditis d. Requesting antibiotics before dental surgery for individuals with rheumatoid arthritis SOLUTION- a. Prompt recognition and treatment of streptococcal pharyngitis The nurse should emphasize the need for prompt and adequate treatment of streptococcal pharyngitis infection, which can lead to the complication of rheumatic fever. The patient had myocarditis and is now experiencing fatigue, weakness, palpitations, and dyspnea at rest. The nurse assesses pulmonary crackles, edema, and weak peripheral pulses. Sinoatrial tachycardia is evident on the cardiac monitor. The Doppler echocardiography shows dilated cardiomyopathy. What collaborative and nursing care of this patient should be done to improve cardiac output and the quality of life (select all that apply.)? a. Decrease preload and afterload. b. Relieve left ventricular outflow obstruction. c. Control heart failure by enhancing myocardial contractility. d. Improve diastolic filling and the underlying disease process. e. Improve ventricular filling by reducing ventricular contractility. SOLUTION- a. Decrease preload and afterload. c. Control heart failure by enhancing myocardial contractility. The patient is experiencing dilated cardiomyopathy. To improve cardiac output and quality of life, drug, nutrition, and cardiac rehabilitation will be focused on controlling heart failure by decreasing preload and afterload and improving cardiac output, which will improve the quality of life. Relief of left ventricular outflow obstruction and improving ventricular filling by reducing ventricular contractility is done for hypertrophic cardiomyopathy. There are no specific treatments for restrictive cardiomyopathy, but interventions are aimed at improving diastolic filling and the underlying disease process. A 55-yr-old female patient develops acute pericarditis after a myocardial infarction. Which assessment finding indicates a possible complication? a. Presence of a pericardial friction rub b. Distant and muffled apical heart sounds c. Increased chest pain with deep breathing d. Decreased blood pressure with tachycardia SOLUTION- d. Decreased blood pressure with tachycardia Cardiac tamponade is a serious complication of acute pericarditis. Signs and symptoms include narrowed pulse pressure, tachypnea, tachycardia, a decreased cardiac output, and decreased blood pressure. The other symptoms are consistent with acute pericarditis. When caring for a patient with infective endocarditis, the nurse will assess the patient for which vascular manifestations (select all that apply.)? a. Osler's nodes b. Janeway's lesions c. Splinter hemorrhages d. Subcutaneous nodules e. Erythema marginatum lesions SOLUTION- a. Osler's nodes Infections in close proximity to the brain can migrate into the brain. A skull fracture impairs the protection of the brain, and infection could occur. Endocarditis can release organisms in the bloodstream that mobilize to the brain. A scalp laceration does not lead to a brain abscess. The patient's magnetic resonance imaging revealed the presence of a brain tumor. The nurse anticipates which treatment modality? a. Surgery b. Chemotherapy c. Radiation therapy d. Biologic drug therapy SOLUTION- a. Surgery Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery. A 32-yr-old female patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement? a. Serum sodium of 120 mEq/L b. Urine specific gravity of 1.001 c. Fasting blood glucose of 80 mg/dL d. Serum osmolality of 290 mOsm/kg SOLUTION- d. Serum osmolality of 290 mOsm/kg Laboratory findings in diabetes insipidus include an elevation in serum osmolality and serum sodium and a decrease in urine specific gravity. Normal serum osmolality is 275 to 295 mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and normal specific gravity is 1.003 to 1.030. Elevated blood glucose levels occur with diabetes mellitus. A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why are IV fluids being decreased and enteral feedings started? a. Free water should be avoided. b. Sodium restrictions can be managed. c. Dehydration can be better avoided with feedings. d. Malnutrition promotes continued cerebral edema. SOLUTION- d. Malnutrition promotes continued cerebral edema. A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings. Excess intravenous fluid administration will also increase cerebral edema. The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for (select all that apply.)? a. Seizures b. Vision loss c. Cerebral edema d. Pituitary dysfunction e. Parathyroid dysfunction f. Focal neurologic deficits SOLUTION- a. Seizures b. Vision loss c. Cerebral edema d. Pituitary dysfunction f. Focal neurologic deficits Brain tumors can cause a wide variety of symptoms depending on location such as seizures, vision loss, and focal neurologic deficits. Tumors can put pressure on the pituitary, leading to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland. A patient has a systemic blood pressure of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? a. High blood flow to the brain b. Normal intracranial pressure c. Impaired blood flow to the brain d. Adequate autoregulation of blood flow SOLUTION- c. Impaired blood flow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80 mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required. The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? a. Tonic spasms of the legs b. Curling in a fetal position c. Arching of the neck and back d. Resistance to flexion of the neck SOLUTION- d. Resistance to flexion of the neck Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation. A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? a. Test the drainage for the presence of glucose. b.Apply a loose gauze pad under the patient's nose. c. Place the patient in a modified Trendelenburg position. d.Ask the patient to gently blow the nose to clear the drainage. SOLUTION- b. Apply a loose gauze pad under the patient's nose. specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin). What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? a. Monitor fluid and electrolyte status carefully. b. Position the patient in a high Fowler's position. c.Administer vasoconstrictors to maintain cerebral perfusion. d. Maintain physical restraints to prevent episodes of agitation. SOLUTION- a. Monitor fluid and electrolyte status carefully. Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP. The nurse prepares to administer temozolomide (Temodar) to a 59-yr-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? a. Serum potassium and serum sodium levels b. Urine osmolality and urine specific gravity c. Absolute neutrophil count and platelet count d. Cerebrospinal fluid pressure and cell count SOLUTION- c. Absolute neutrophil count and platelet count Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be greater than 1500/ìL and platelet count greater than 100,000/ìL. The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? a.Administer IV mannitol b. Ventilator use to hyperoxygenate the patient c. Use strict aseptic technique with dressing changes. d. Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF). SOLUTION- c. Use strict aseptic technique with dressing changes. The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care. The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? a. Document the ICP reading in the chart. b. Determine if the patient has a headache. c.Assess the patient's level of consciousness. d. Position the patient with head elevated 60 degrees. SOLUTION- c. Assess the patient's level of consciousness. The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness. Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The nurse should know that the patient may have elevated intracranial pressure (ICP), causing serious disruption of motor fibers in the midbrain and brainstem and will expect the patient's posture to look like which posture represented below? SOLUTION- Decerebrate posture is all four extremities in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and may be seen with traumatic brain injury. In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? a. Serum sodium and potassium increase. b. Serum sodium and potassium decrease. c. Edema and arterial blood gases improve. d. Diuresis occurs and hematocrit decreases. SOLUTION- d. Diuresis occurs and hematocrit decreases. In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs so potassium levels decrease at the end of the emergent phase when fluid levels normalize. A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? anterior chest and neck d. A 42-yr-old patient who is scheduled for skin grafting of a burn wound SOLUTION- c. A 53-yr-old patient with a chemical burn to the anterior chest and neck The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma. Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA. An older adult patient is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home? a. Cook for her. b. Stop her from smoking. c. Install tap water anti-scald devices. d. Be sure she uses an open space heater. SOLUTION- c. Install tap water anti-scald devices. Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged. A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury (select all that apply.)? a. Singed nasal hair b. Generalized pallor c. Painful swallowing d. Burns on the upper extremities e. History of being involved in a large fire SOLUTION- a. Singed nasal hair b. Generalized pallor c. Painful swallowing e. History of being involved in a large fire Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color. A patient with type 2 diabetes mellitus is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient? a. Replace the blood lost. b. Maintain a neutral pH. c. Maintain fluid balance. d. Replace serum potassium. SOLUTION- c. Maintain fluid balance. This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? a. Skin is hard with a dry, waxy white appearance. b. Skin is shiny and red with clear, fluid-filled blisters. c. Skin is red and blanches when slight pressure is applied. d. Skin is leathery with visible muscles, tendons, and bones. SOLUTION- b. Skin is shiny and red with clear, fluid-filled blisters. Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones. The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care (select all that apply.)? a. Escharotomy b.Administration of diuretics c. IV and oral pain medications d. Daily cleansing and debridement e.Application of topical antimicrobial agent SOLUTION- a. Escharotomy c. IV and oral pain medications d. Daily cleansing and debridement e. Application of topical antimicrobial agent An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion. When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient (select all that apply.)? a. The exercises are the only way to prevent contractures. b. Active and passive ROM maintain function of body parts. c. ROM will show the patient that movement is still possible. d. Movement facilitates mobilization of leaked exudates back into the vascular bed. e. Active and passive ROM can only be done while the dressings are being changed. SOLUTION- b. Active and passive ROM maintain function of body parts. c. ROM will show the patient that movement is still possible. Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day. The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation (select all that apply.)? a. Urine output is 46 mL/hr. b. Heart rate is 94 beats/min. c. Urine specific gravity is 1.040. d. Mean arterial pressure is 54 mm Hg. e. Systolic blood pressure is 88 mm Hg. SOLUTION- a. Urine output is 46 mL/hr. b. Heart rate is 94 beats/min. Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030. A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? a. The total 24-hour fluid requirement should be administered in the first 8 hours. b. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. c. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. d. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. SOLUTION- c. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours. When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. Mannitol 75 g IV b. Urine for myoglobulin c. Lactated Ringer's solution at 25 mL/hr d. Sodium bicarbonate 24 mEq every 4 hours SOLUTION- c. Lactated Ringer's solution at 25 mL/hr Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's solution at 2 to 4 mL/kg/%TBSA, a rate sufficient to The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and depression that patients may experience. Zolpidem promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant. The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? a. Blisters b. Reddening of the skin c. Destruction of all skin layers d. Damage to sebaceous glands SOLUTION- b. Reddening of the skin The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.