Med-Surg III FINAL

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A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client's diagnosis?
A. Smoking a pack of cigarettes a day for 30 years
B. Taking hormone-replacement therapy
C. Eating foods with preservatives
D. Past employment involving asbestos

35.Answer A is correct. Cigarette smoking is the number one cause of bladder cancer. Answer B is incorrect because it is associated with breast cancer, not bladder cancer. Answer C is wrong because it is a primary cause of gastric cancer. Answer D is incorrect because it is a cause of certain types of lung cancer.

The nurse is administering Dilantin (phenytoin) via nasogastric (NG) tube. When giving the medication, the nurse should:
A.Flush the NG tube with 2-4mL of water before giving the medication
B.Administer the medication, flush with 5mL of water, and clamp the NG tube
C.Flush the NG tube with 5mL of normal saline and administer the medication
D.Flush the NG tube with 2-4oz. of water before and after giving the medication

40.Answer D is correct. The nurse should flush the NG tube with 2-4oz. of water before and after giving the medication. Answers A and B are incorrect because they do not use sufficient amounts of water. Answer C is incorrect because water, not normal saline, is used to flush the NG tube.

The nurse is preparing to walk the post-operative client for the first time since surgery. Before walking the client, the nurse should:
A.Give the client pain medication
B.Assist the client in dangling his legs
C.Have the client breathe deeply
D.Provide the client with additional fluids

43.Answer B is correct. Before walking the client for the first time since surgery, the nurse should ask the client to sit on the side of the bed and dangle his legs, to prevent postural hypotension. Pain medication should not be given before walking; therefore, answer A is incorrect. Answers C and D have no relationship to walking the client; therefore, they are incorrect.

While performing a neurological assessment on a client with a closed head injury, the licensed practical nurse notes a positive Babinski reflex. The nurse should:
A.Recognize that the client's condition is improving
B.Reposition the client and check reflexes again
C.Do nothing because the finding is an expected one
D.Notify the charge nurse of the finding

44.Answer D is correct. A positive Babinski reflex in adults should be reported to the charge nurse because it indicates an abnormal finding. Answer A is incorrect because a positive Babinski sign in the adult is abnormal, therefore it does not indicate that the client's condition is improving. Answer B is incorrect because changing the position will not alter the finding. Answer C is incorrect because a positive Babinski reflex is an expected finding in the infant but not in adults.

A nurse finds her neighbor lying unconscious in the doorway of her bathroom. After determining that the victim is unresponsive, the nurse should:
A.Start cardiac compression
B.Give two slow deep breaths
C.Open the airway using the head-tilt chin-lift maneuver
D.Call for help

Answer D is correct. According to the American Heart Association, the nurse should call for help before instituting CPR. Answer A is incorrect because the nurse would first call for help. The nurse would not start cardiac compressions before evaluating the client's carotid pulse. Answer B is incorrect because the nurse would first call for help. The nurse would not administer rescue breathing until she established that the client was not breathing on her own. Answer C is incorrect because the nurse would open the airway after calling for help.

A client receiving chemotherapy has Sjogren's syndrome. The nurse can help relieve the discomfort caused by Sjogren's syndrome by:
A.Providing cool, noncarbonated beverages
B.Instilling eyedrops
C.Administering prescribed antiemetics
D.Providing small, frequent meals

Answer B is correct. The client with Sjogren's syndrome complains of dryness of the eyes. The nurse can help relieve the client's discomfort by instilling eyedrops. Answers A, B, and C do not relieve the symptoms of Sjogren's syndrome; therefore, they are incorrect.

The physician has ordered an injection of morphine for a client with post-operative pain. Before administering the medication, it is essential that the nurse assess the client's:
A.Heart rate
B.Respirations
C.Temperature
D.Blood pressure

Answer B is correct. Morphine can severely depress the client's respirations. Answer A is incorrect because the assessment of heart rate, a part of pain assessment, is not an essential assessment for administering morphine. Answer C is incorrect because temperature is not affected by the administration of morphine. Answer D is incorrect because assessment of blood pressure, a part of pain assessment, is not an essential assessment for administering morphine.

The nurse is caring for a client following a pneumonectomy. Which nursing intervention will help prevent an embolus?
A.Encouraging the client to use an incentive spirometer
B.Administering thrombolytic medication as ordered
C.Telling the client to turn, cough, and breathe deeply
D.Ambulating the client as soon as possible

Answer D is correct. Ambulating the client as soon as possible prevents venous stasis and helps to prevent embolus formation. Answers A and C are measures to increase the effectiveness of respirations and help to prevent pneumonia; therefore, they are incorrect. Answer B is a treatment to break up an existing embolus; therefore, it is incorrect.

A post-operative client has called the nurse's station with complaints of pain. The first action by the nurse should be to:
A.Check to see when the client received pain medication
B.Administer the prescribed pain medication
C.Notify the charge nurse of the client's complaints
D.Assess the location and character of the client's pain

Answer D is correct. The nurse should first assess the client to determine the location and character of the pain. Answers A, B, and C are incorrect because they are not the first action that the nurse should take.

The physician has ordered a PSA and acid phosphatase for a male client admitted with complaints of dysuria. The nurse knows that a PSA and acid phosphatase are screening tests for:
A.Cancer of the bladder
B.Cancer of the prostate
C.Cancer of the vas deferens
D.Cancer of the testes

Answer B is correct. The PSA (prostate specific antigen) and acid phosphatase are valuable screening tests for cancer of the prostate. The PSA is not a screening test for cancers of the bladder, vas deferens, or testes; therefore, answers A, C, and D are incorrect.

The nurse is caring for a client 1 week post-burn injury. The nurse should expect the client to benefit from a diet that is:
A.High in protein, low in sodium, and low in carbohydrates
B.Low in fat, low in sodium, and high in calories
C.High in protein, high in carbohydrates, and high in calories
D.High in protein, high in fat, and low in calories

Answer C is correct. The client recovering from a burn injury should have a diet that is high in protein, high in carbohydrates, and high in calories to meet the body's requirements for tissue repair. Answer A is incorrect because the client needs additional carbohydrates. Answer B is incorrect because the client would benefit from increased fat. Answer D is incorrect because the client needs additional calories.

) A patient with myasthenia gravis (MG) is admitted to the hospital with severe weakness and acute respiratory insufficiency. The health care provider performs a Tensilon test to distinguish between myasthenic crisis and cholinergic crisis. During the test, it will be most important to monitor the patient's
a. pupillary size.
b. muscle strength.
c. respiratory function.
d. level of consciousness (LOC).

Correct Answer: C
Rationale: Because the patient's respiratory insufficiency is life threatening, it will be most important to monitor respiratory function during the Tensilon test. Pupillary size and muscle strength may also be affected by the test but are not as important to monitor. LOC is not typically affected by MG, although the LOC may be affected by oxygenation in this patient.

When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to
a. anticipate the need for weekly plasmapheresis treatments.
b. protect the extremities from injury due to poor sensory perception.
c. do frequent weight-bearing exercise to prevent muscle atrophy.
d. perform necessary physically demanding activities in the morning.

Correct Answer: D
Rationale: Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or in situations where corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.

A hospitalized patient with myasthenia gravis (MG) has a nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired swallowing. To promote nutrition, the nurse suggests that before meals the patient should avoid
a. watching television.
b. talking on the phone.
c. typing on the computer.
d. ambulating in the halls.

Correct Answer: B
Rationale: The same muscles are used for talking and swallowing, so the patient should avoid fatiguing the muscles of the mouth and throat before meals. The other activities will not affect the muscles used for chewing and swallowing.

When teaching the spouse of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that
a. the most important risk factor for AD is a family history of the disorder.
b.a diagnosis of AD can be made only when other causes of dementia have been ruled out.
c.new drugs have been shown to reverse AD dramatically in some patients.
d.the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.

Correct Answer: B
Rationale: The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well.

The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer's disease (AD). An appropriate intervention for this problem is to
a.maintain a consistent daily routine for the patient's care.
b.encourage the patient to discuss events from the past.
c.reorient the patient to the date and time every few hours.
d.provide the patient with current newspapers and magazines.

Correct Answer: A
Rationale: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read.

When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care?
a.Ask the patient why the wandering episodes have occurred.
b.Reorient the patient to the new living situation several times daily.
c.Place the patient in a room close to the nurses' station.
d.Have the family bring in familiar items from the patient's home.

Correct Answer: C
Rationale: Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. Use of "why" questions is frustrating for the patient with AD, who are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help to prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.

During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient?
a.Move the patient to a quieter room at night.
b.Open the blinds in the patient's room and provide frequent activities.
c.Have the patient take a brief mid-morning nap.
d.Provide hourly orientation to time of day.

Correct Answer: B
Rationale: The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties.

A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome
a. results from an acute infection and inflammation of the peripheral nerves.
b. is due to an immune reaction that attacks the covering of the peripheral nerves.
c. is caused by destruction of the peripheral nerves after exposure to a viral infection.
d. results from degeneration of the peripheral nerve caused by viral attacks.

Correct Answer: B
Rationale: Guillain-Barré syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate.

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is
a. monitoring the cardiac rhythm continuously.
b. determining the level of consciousness q2hr.
c. evaluating sensation and strength of the extremities.
d. performing constant evaluation of respiratory function.

Correct Answer: D
Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?
a. The patient complains of severe tingling pain in the feet.
b. The patient has continuous drooling of saliva.
c. The patient's blood pressure (BP) is 106/50 mm Hg.
d. The patient's quadriceps and triceps reflexes are absent.

Correct Answer: B
Rationale: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include
a. intubation and mechanical ventilation.
b. insertion of a nasogastric (NG) feeding tube.
c. administration of methylprednisolone (Solu-Medrol).
d. IV infusion of immunoglobulin (Sandoglobulin).

Correct Answer: D
Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

A male client is having a tonic-clonic seizures. What should the nurse do first?
a. Elevate the head of the bed.
b. Restrain the client's arms and legs.
c. Place a tongue blade in the client's mouth.
d. Take measures to prevent injury.

Answer D. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.

A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary."
b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss."
c. "It must be hard to accept the permanency of your paralysis."
d. "You'll first regain use of your legs and then your arms."

Answer A. The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis?
a. Anxiety
b. Powerlessness
c. Ineffective denial
d. Risk for disuse syndrome

Answer B. This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can't perform even simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with ALS, the client's comment specifically refers to an inability to act autonomously. A diagnosis of Ineffective denial would be indicated if the client didn't seem to perceive the personal relevance of symptoms or danger.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:
a. prevent respiratory alkalosis.
b. lower arterial pH.
c. promote carbon dioxide elimination.
d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain?
a. Sternal rub
b. Nail bed pressure
c. Pressure on the orbital rim
d. Squeezing of the sternocleidomastoid muscle

Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:
a. Eating large, well-balanced meals
b. Doing muscle-strengthening exercises
c. Doing all chores early in the day while less fatigued
d. Taking medications on time to maintain therapeutic blood levels

Answer D. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has history of:
a. Seizures or trauma to the brain
b. Meningitis during the last 5 years
c. Back injury or trauma to the spinal cord
d. Respiratory or gastrointestinal infection during the previous month.

Answer D.
Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery.

A female client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?
a. Giving client full control over care decisions and restricting visitors
b. Providing positive feedback and encouraging active range of motion
c. Providing information, giving positive feedback, and encouraging relaxation
d. Providing intravaneously administered sedatives, reducing distractions and limiting visitors

Answer C.
The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion

A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
a. Observing for agitation and paranoia
b. Assisting the patient with active range of motion (ROM)
c. Using simple words and phrases to explain procedures
d. Administer muscle relaxants as needed for muscle spasms

Correct Answer: B
Rationale: ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A 42-year-old patient who was adopted at birth is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the
a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms.
b. need to take prophylactic antibiotics to decrease the risk for pneumonia.
c. lifestyle changes, such as increased exercise, that delay disease progression.
d. availability of genetic testing to determine the HD risk for the patient's children.

Correct Answer: D
Rationale: Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD given that HD involves an increase in dopamine. The patient is at risk for pneumonia in the later stages of HD, but this patient has early HD. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room? (Select all that apply.)
a. Suction tubing
b. Oxygen mask
c. Nasogastric tube
d. Siderail pads
e. Tongue blade
f. Oral airway

Correct Answer: A, B, D
Rationale: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades or oral airways during a seizure is contraindicated.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:
1.A positive Brudzinski's sign
2.A negative Kernig's sign
3.Absence of nuchal rigidity
4.A Glascow Coma Scale score of 15

Correct Answer: 1
Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

Which of the following pathologic processes is often associated with aseptic meningitis?
1.Ischemic infarction of cerebral tissue
2.Childhood diseases of viral causation such as mumps
3.Brain abscesses caused by a variety of pyogenic organisms
4.Cerebral ventricular irritation from a traumatic brain injury

Correct Answer: 2
Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles, mumps, herpes, and leukemia. Incidences of brain abscess are high in bacterial meningitis, and ischemic infarction of cerebral tissue can occur with tubercular meningitis. Traumatic brain injury could lead to bacterial (not viral) meningitis.

A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client?

a. A private room down the hall from the nurses' station
b. An isolation room three doors from the nurses' station
c. A semiprivate room with a 32-year-old client who has viral meningitis
d. A two-bed room with a client who previously had bacterial meningitis

Answer B.
A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.

A patient is deemed to be potentially afflicted with meningitis. Which among these signs can potentially be symptoms of meningitis?
a. Fever
b. Vomiting
c. Low Light Tolerance
d. All of the above.

Correct Answer: D
All of those symptoms are linked with the presence of meningitis

The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:
a. Pain on flexion of the hip and knee
b. Nuchal rigidity on flexion of the neck
c. Pain when the head is turned to the left side
d. Dizziness when changing positions

Correct Answer: A
Kernig's sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig's sign

Myasthenic crisis and cholinergic crisis are the major complications of myasthenia gravis. Which of the following is essential nursing knowledge when caring for a client in crisis?
a. Weakness and paralysis of the muscles for swallowing and breathing occur in either crisis
b. Cholinergic drugs should be administered to prevent further complications associated with the crisis
c. The clinical condition of the client usually improves after several days of treatment
d. Loss of body function creates high levels of anxiety and fear

Answer: A
Rationale: The client cannot handle his own secretions, and respiratory arrest may be imminent. Atropine may be administered to prevent crisis. Anticholinergic drugs are administered to increase the levels of acetylcholine at the myoneural junction. Cholinergic drugs mimic the actions of the parasympathetic nervous system and would not be used.

After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care?
a.Rapidly infuse cold normal saline.
b.Avoid the use of sedative medications.
c.Check neurologic status every 30 minutes.
d.Rewarm if temperature is >91° F (32.8° C).

ANS: A
When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Since hypothermia will decrease brain activity, neurologic assessment every 30 minutes is not needed. Sedative medications are administered during therapeutic hypothermia.

When preparing to rewarm a patient with hypothermia, the nurse will plan to
a.attach a cardiac monitor.
b.insert a urinary catheter.
c.assist with endotracheal intubation.
d.have sympathomimetic drugs available.

ANS: A
Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation.

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F, which assessment indicates that the nurse should discontinue the rewarming?
a.The patient stops shivering.
b.The BP decreases to 85/40 mm Hg.
c.The patient develops atrial fibrillation.
d.The core temperature is 94° F (34.4° C).

ANS: D
A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?
a.Encourage family members to remain at the bedside.
b.Apply soft restraints to protect the patient from injury.
c.Keep the room well-lighted to improve patient orientation.
d.Minimize contact with the patient to decrease sensory input.

ANS: A
Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?
a.Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
b.Emphasize the importance of hand washing to prevent spread of infection.
c.Immunize adolescents and college freshman against Neisseria meningitides.
d.Encourage adolescents and young adults to avoid crowded areas in the winter.

ANS: C
The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN?
a.The bedrails at the head and foot of the bed are both elevated.
b.The patient receives a regular diet from the dietary department.
c.The nursing assistant goes into the patient's room without a mask.
d.The lights in the patient's room are turned off and the blinds are shut.

ANS: C
Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?
a.The patient has a positive Kernig's sign.
b.The patient complains of having a stiff neck.
c.The patient's temperature is 101° F (38.3° C).
d.The patient's blood pressure is 86/42 mm Hg.

ANS: D
Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all of these collaborative interventions. Which action should the nurse take first?
a.Administer ceftizoxime (Cefizox) 1 g IV.
b.Use a cooling blanket to lower temperature.
c.Swap the nasopharyngeal mucosa for cultures.
d.Give acetaminophen (Tylenol) 650 mg PO.

ANS: C
Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply.
1.Decerebrate posturing
2.Dilated non reactive pupils
3.Deep tendon reflexes
4.Absent corneal reflex

Correct Answer: 2, 3, 4
Rationale: A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.

A 21-year-old is dying after an automobile accident. The family members want to donate the patient's organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when
a.the patient is flaccid and unresponsive.
b.CPR is ineffective in restoring heartbeat.
c.the patient is apneic and without brainstem reflexes.
d.respiratory efforts cease and no apical pulse is audible.

ANS: C
The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead.

The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
a. The client receiving linear accelerator radiation therapy for lung cancer
b. The client with a radium implant for cervical cancer
c. The client who has just been administered soluble brachytherapy for thyroid cancer
d. The client who returned from placement of iridium seeds for prostate cancer

Correct Answer: A
Rationale: The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. The clients in answers B, C, and D pose a risk to the pregnant nurse. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks.

The nurse is caring for a client with an internal radiation implant. When caring for the client, the nurse should observe which of the following principles?

a) limit the time with the client to 1 hour per shift
b) do not allow pregnant women into the client's room
c) remove the dosimeter badge when entering the client's room
d) individuals younger than 16 years old may be allowed to go in the room as long as they are 6 feet away from the client

Correct Answer: B
Rationale: The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room.

A cervical radiation implant is placed in the client for the treatment of cervical cancer. The nurse initiates what most appropriate activity order for this client?

a) bed rest
b) out of bed ad lib
c) out of bed in a chair only
d) ambulation to the bathroom only

Correct Answer: A
Rationale: The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. The nurse avoids turning the client on the side. If turning is absolutely necessary, a pillow is placed between the knees and, with the body in straight alignment, the client is logrolled.

The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to:

a) call the physician
b) reinsert the implant into the vagina immediately
c) pick up the implant with gloved hands and flush it down the toilet
d) pick up the implant with long-handled forceps and place it in a lead container

Correct Answer: D
Rationale: A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container. Options A, B, and C are inaccurate interventions.

The nurse at the clinic is interviewing a 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)?
a.Pap testing
b.Tobacco use
c.Sunscreen use
d.Mammography
e. Colorectal screening

ANS: A, C, D, E
The patient's age, gender, and history indicate a need for screening and/or teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.

While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse about the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
a."Benign tumors do not cause damage to other tissues."
b."Benign tumors are likely to recur in the same location."
c."Malignant tumors may spread to other tissues or organs."
d."Malignant cells reproduce more rapidly than normal cells."

ANS: C
The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur.

The nurse in the outpatient clinic is caring for a 50-year-old who smokes heavily. To reduce the patient's risk of dying from lung cancer, which action will be best for the nurse to take?
a.Educate the patient about the seven warning signs of cancer.
b.Plan to monitor the patient's carcinoembryonic antigen (CEA) level.
c.Discuss the risks associated with cigarettes during every patient encounter.
d.Teach the patient about the use of annual chest x-rays for lung cancer screening.

ANS: C
Education about the risks associated with cigarette smoking is recommended at every patient encounter, since cigarette smoking is associated with multiple health problems. A tumor must be at least 0.5 cm large before it is detectable by current screening methods and may already have metastasized by that time. Oncofetal antigens such as CEA may be used to monitor therapy or detect tumor reoccurrence, but are not helpful in screening for cancer. The seven warning signs of cancer are actually associated with fairly advanced disease.

After the nurse has finished teaching a patient who is scheduled to receive external beam radiation for abdominal cancer about appropriate diet, which dietary selection by the patient indicates that the teaching has been effective?
a.Fresh fruit salad
b.Roasted chicken
c.Whole wheat toast
d.Cream of potato soup

ANS: B
To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose-intolerance may develop secondary to radiation, so dairy products also should be avoided.

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." An appropriate intervention for the nurse to plan with the patient is to
a.minimize activity until the treatment is completed.
b.exercise vigorously when fatigue is not as noticeable.
c.establish a time to take a short walk almost every day.
d.consult with a psychiatrist for treatment of depression.

ANS: C
Walking programs are used to keep the patient active without excessive fatigue. Vigorous exercise when the patient is less tired may lead to increased fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility.

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. Which patient statement indicates that the nurse's teaching about management of the skin reaction has been effective?
a."I can buy some aloe vera gel to use on the area."
b."I will expose the treatment area to a sun lamp daily."
c."I can use ice packs to relieve itching in the treatment area."
d."I will scrub the area with warm water to remove the scales."

ANS: A
Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.

Which nursing action will be most effective in improving oral intake for a patient with the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers?
a.Offer the patient frequent small snacks between meals.
b.Assist the patient to choose favorite foods from the menu.
c.Provide education about the importance of nutritional intake.
d.Apply the ordered anesthetic gel to oral lesions before meals.

ANS: D
Since the etiology of the patient's poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition, but would not be as helpful for this patient.

The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?
a.Orange sherbet
b.Fresh fruit salad
c.Strawberry yogurt
d.Cream cheese bagel

ANS: C
Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Orange sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein.

When caring for a patient with a temporary radioactive cervical implant, which action by nursing assistive personnel (NAP) indicates that the RN should intervene?
a.The NAP flushes the toilet once after emptying the patient's bedpan.
b.The NAP stands by the patient's bed for 30 minutes talking with the patient.
c.The NAP places the patient's bedding in the laundry container in the hallway.
d.The NAP gives the patient an alcohol-containing mouthwash to use for oral care.

ANS: B
Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.

A client had a modified radical mastectomy of the left breast. What would be important for the nurse to include in a discharge teaching plan? (Select all that apply)
1. Avoid any needle sticks in the left arm.
2. Avoid abduction & external rotation of left arm.
3. Begin pendulum arm swings & full ROM immediately.
4. Elevate left arm on pillows to prevent edema.
5. Have all blood pressure readings taken on the right arm.
6. Massage wound site with essential oils once incision has healed.

Correct Answer: 1, 4, 5
Gradual abduction and external rotation of the affected arm is encouraged, not avoided. Arm exercises and full ROM are started after the incision has healed but the patient may begin finger, wrist, and hand exercises to facilitate muscle contraction and to help prevent edema.

A client with laryngeal cancer has undergone laryngectomy and is receiving radiation therapy to the head and neck. The nurse should monitor the client for which adverse effects of external radiation? SELECT ALL THAT APPLY.
A. Xerostomia
B. Stomatitis
C. Thrombocytopenia
D. Cystitis
E. Dysgeusia
F. Leukopenia

Correct Answer: A, B, E
Rationale: Radiation of the head and neck commonly cause xerostomia (dry mouth), stomatitis (irritation of the oral mucous membranes), and disgeusia (diminished sense of taste). Thrombocytopenia and leukopenia may occur after systemic therapy. Cystitis may occur after radiation of the GU system.

After sustaining a closed head injury, the client is prescribed Phenytoin (Dilantin) IV for seizure prophylaxis. Which nrs interventions are necessary when administering drug? (Select all that apply).
a.Administer phenytoin through any peripheral IV site.
b.Mix IV dose in solutions containing D5W
c.Monitor ECG, BP, and respiratory status continuously when administering drug.
d.Don't use an inline filter when administering drug.
e.Know that early toxicity may cause drowsiness, nausea, vomiting, nystagmus, ataxia, dysarthria, tremor, and slurred speech.

Correct Answer: C, E
Rationale: Phenytoin shouldn't be administered by IV in veins in the back of the hand; larger veins are needed to prevent discoloration associated with purple glove syndrome. IV doses must be mixed with normal saline and used within 30 min. Mixtures with D5W will precipitate. Use of an inline filter is recommended.

The nurse is caring for a client who has been in a coma for 4 months. The physicians have approached the client's family about ceasing life support. Which of the following comments, if said by the client's family, demonstrates a correct understanding of the difference between a persistent vegetative state and brain death?

A."The diagnosis of persistent vegetative state requires that the condition has continued for at least six months."
B."Brain death is the cessation and irreversibility of all brain functions, including the brainstem."
C."Persistent vegetative state is a temporary condition of complete unawareness of self and the environment and loss of all cognitive functions."
D."Brain death has occurred when there is little evidence of cerebral or brainstem function for an extended period in any client."

Correct Answer: B
Rationale: The diagnosis of persistent vegetative state requires that the condition has continued for at least one month. # 1 is incorrect because the statement has six months, not one month in it. Brain death is the cessation and irreversibility of all brain functions, including the brainstem. # 2 is a correct statement. Persistent vegetative state (also called irreversible coma) is a permanent condition of complete unawareness of self and the environment and loss of all cognitive functions. # 3 is incorrect because it says it is a temporary state, and it is permanent. Brain death has occurred when there is no evidence of cerebral or brainstem function for an extended period (usually 6 to 24 hours) in a client who has a normal body temperature and is not affected by a depressant drug or alcohol poisoning. # 4 is incorrect because there will be no evidence, not a little evidence of cerebral or brainstem function. Also it is not "in any client" because consideration is given to clients without normal body temperatures or with drug or alcohol poisoning.

Which of the following assessment findings indicated increased intracranial pressure? Select all that apply

a) headache
b) tachycardia
c) slow respiration
d) narrowing of pulse pressure
e) slow, bounding pulse
f) hyperthermia

Correct Answer: A, C, E, F
Rationale: increased ICP is characterized by headache, nausea and vomiting, diplopia, increased systolic BP, slow respiration, slow bounding pulse (bradycardia, not tachycardia), widening of pulse pressure (NOT narrowing), hyperthermia/hypothermia, altered LOC, papilledema.

When developing a health teaching plan for a 65-year-old patient with all these risk factors for coronary artery disease (CAD), the nurse will focus on the
a.family history of heart disease.
b.increased risk associated with the patient's ethnicity.
c.high incidence of cardiovascular disease in older people.
d.low activity level the patient reports.

Correct Answer: D
Rationale: Because family history, ethnicity, and age are nonmodifiable risk factors, the nurse should focus on the patient's activity level. An increase in activity will help reduce the patient's risk for developing CAD.

Modifiable risk factors that increase the risk of acute myocardial infarction (MI) include all of the following except:

a. Hypertension
b. Smoking
c. Food allergies
d. Lack of physical activity

Correct Answer: C
Rationale: Modifiable risk factors - cigarette smoking, abnormal blood lipid levels, hypertension, diabetes, abdominal obesity, a lack of physical activity, and alcohol over-consumption account for more than 90% of the risk of an initial acute MI.

A nurse assesses a postoperative client who has a rapid, weak pulse; urine output less than 30 ml/hr; and decreased blood pressure. The client's skin is cool and clammy. What complication should the nurse suspect?

A.Thrombophlebitis
B.Aspiration pneumonia
C.Wound dehiscence
D.Hypovolemic shock

Correct Answer: D
Rationale: The nurse should expect hypovolemic shock. Thrombophlebitis, aspiration pneumonia, and wound dehiscence could have similar symptoms with the addition of one more symptom. Thrombophlebitis is calf inflammation or pain. Aspiration pneumonia is shortness of breath and cough. Wound dehiscence pertains to opening of the wound stitches.

A surgical client has just been admitted to the recovery room after a colon resection. You check the dressing for indications of which of the following complications?

A. peritonitis
B. paralytic ileus
C. dehiscense
D. hemorrhage

Correct Answer: D
Rationale: In the immediate postoperative phase, hemorrhage is a possibility. Peritonitis, paralytic ileus, and dehiscense are all complications that may occur later, but not immediately after surgery.

A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care?
a. Esophagitis
b. Leukopenia
c. Fatigue
d. Skin irritation

Correct Answer: B
Rationale: Leukopenia refers to a decrease in the total WBC count. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. Which of the following is the appropriate nursing intervention?

a) notify the physician
b) measure abdominal girth
c) irrigate the nasogastric tube
d) continue to monitor the drainage

Correct Answer: D
Rationale: Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then to yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the physician at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific physician orders to do so.

A patient with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. All of these actions have been prescribed by the physician. Which one should the nurse accomplish first?
A) Give oxygen per non-rebreather mask at 100% FiO2.
B) Infuse lactated Ringer's solution at 150 mL/hr.
C) Give morphine sulfate 4 to 10 mg IV for pain control.
D) Insert a 14-Fr retention catheter.

Correct Answer: A
Rationale: Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the patient's tissue oxygenation at an optimal level. The other actions should be implemented as quickly as possible after the oxygen therapy is initiated.

While working in the emergency department, the RN admits a patient with extensive burn injuries caused by a fire at the patient's home. Which assessment should the RN accomplish first?
A) TBSA burned
B) Breath sounds
C) Pain level
D) Blood pressure

Correct Answer: B
Rationale: Respiratory complications are a major cause of death in patients who have burn injuries. Adventitious breath sounds such as wheezes or decreased breath sounds may indicate the need for immediate intubation or tracheotomy.

Which assessment information about a 60-kg patient who was admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area will be of most concern to the nurse?
A) The bowel sounds are absent.
B) The pulse oximetry level is 91%.
C) The serum potassium level is 8.1 mEq/L.
D) The urine output since admission is 370 mL.

Correct Answer: C
Rationale: An elevated serum potassium level can cause cardiac arrest. The other findings are normal for the patient during the emergent phase of burn injury.

A patient is admitted with a full-thickness scald burn over the abdomen and thighs, and all of these physician orders are received. Which order should be implemented first?
A) Place two large-bore IV lines.
B) Insert a 16-Fr retention catheter.
C) Obtain a complete blood count.
D) Administer tetanus toxoid 0.5 mL.

Correct Answer: A
Rationale: The priority nursing actions at this time are ensuring adequate oxygenation and tissue perfusion. Because there is no indication that the patient is having respiratory difficulties, the initial nursing action should be to start fluid resuscitation, which will require large-bore IV lines. The other actions should also be implemented rapidly but are not the highest-priority actions.

You're caring for a patient with a 25% full-thickness body surface area burn to the face and upper torso. Which initial admission assessment finding would make you suspect inhalation injury?
a. nausea
b. heart rate greater than 100 beats/minute
c. inability to speak
d. edema of the arms

Correct Answer: C
Rationale: Suspect inhalation injury when a patient has suffered burns to his face and torso and can't speak. Nausea isn't a sign of inhalation injury. Tachycardia is a normal finding in patients with burns because of the loss of intravascular fluid. Edema, another predictable response to a burn, results when sodium, water, and protein shift from intravascular to interstitial spaces, decreasing oncotic pressure and increasing capillary permeability.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse calculates that he sustained burns to which percentage of his body?
A. 9%
B. 18%
C. 27%
D. 36%

Correct Answer: C
Rationale: Back (18%) and arm (9%) = 27%.

A female client is brought to the emergency department with second- and third-degree burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?
a. 18%
b. 27%
c. 30%
d. 36%

Correct Answer: D
Rationale: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

The nurse assesses the client for fluid shifting. Fluid shifts that occur during the emergent phase of a burn injury are caused by fluid moving
A. From the vascular to the interstitial space
B. From the extracellular to the intracellular space
C. From the intracellular to the extracellular space
D. From the interstitial to the vascular space

Correct Answer: A
Rationale: In a burn injury, the injured capillaries dilate, and there is increased capillary permeability at the site of the burn, plasma seeps out into the burned tissue, moving from the vascular space into the interstitial space.

A priority nursing diagnosis category for a client with burns during the emergent period would be
A. Excess fluid volume
B. Imbalance nutrition: less than body requirements
C. Risk for injury (falling)
D. Risk for infection

Correct Answer: D
Rationale: Infection is a priority problem for the burned victim because of the loss of skin integrity and alternation in body defenses.

Which of the following activities should the nurse include in the care plan of a client with burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing change
A.Soak the dressing
B.Remove the dressing
C.Administer an analgesic
D.Slit the dressing with blunt scissors

Correct Answer: C
Rationale: Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about ½ hour before the dressing change to promote comfort.

The client with a major burn injury receives TPN. The primary reason for this therapy is to help
A.Correct water and electrolyte imbalances
B.Allow the GI tract to rest
C.Provide supplemental vitamins and minerals
D.Ensure adequate caloric and protein intake

Correct Answer: D
Rationale: Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate.

When an individual is burned there is massive cell destruction resulting in a disruption of the normal homeostasis of the body. The nurse anticipates that the client will be susceptible to which of the following in the early phase of burn care?
A.Hypernatremia
B.Hyponatremia
C.Metabolic alkalosis
D.Hyperkalemia

Correct Answer: D
Rationale: Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hypernatremia may be seen following successful fluid resuscitation. Hyponatremia may develop from excessive suction, diarrhea, or water intake.

) Endotracheal or tracheostomy are placed in clients who have experienced
A.Electrical burns of the hands and arms causing dysrhythmias
B.Thermal burns to the head, face, and airway resulting in hypoxia
C.Chemical burns on the chest and abdomen
D.Secondhand smoke inhalation

Correct Answer: B
Rationale: Airway management is the priority in caring for a burn client. Early endotracheal intubation (preferably orotracheal) is anticipated when significant thermal and smoke inhalation burns occur. In general, the patient with major injuries involving burns to the face and neck requires intubation within 1-2 hours after burn injury.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergent period of burn management. Which of the following indicates that adequate fluid replacement has been achieved in the client?
A.An increase in body weight
B.Fluid intake is less that urinary output
C.Urinary output greater than 35 mL/hour
D.Blood pressure of 90/60mmHG

Correct Answer: C
Rationale: A urinary output of greater than 30mL/hr is considered to be an indicator of adequate fluid replacements in burn clients.

To maintain adequate nutrition for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury, the nurse will plan to
a.Insert a feeding tube and initiate enteral feedings.
b.Infuse total parenteral nutrition via a central catheter.
c.Encourage an oral intake of at least 5000 kcal per day.
d.Administer multiple vitamins and minerals in the IV solution.

ANS: A
Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

A patient with extensive second-degree burns on the legs and trunk is using patient-controlled analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control the pain. Several times during the night, the patient awakens in severe pain, and it takes more than an hour to regain pain relief. The most appropriate action by the nurse is to
a. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain.
b. consult with the patient's health care provider about adding a continuous morphine infusion to the PCA regimen at night.
c. teach the patient to push the button every 10 minutes for an hour before going to sleep even if the pain is minimal.
d. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.

Correct Answer: B
Rationale: Adding a continuous dose of the morphine at night will allow the patient to sleep without being awakened by the pain. Administering a dose of morphine when the patient awakens would not address the problem. Teaching the patient to administer unneeded medication before going to sleep might result in oversedation and respiratory depression. It is inappropriate for the nurse to administer the morphine while the patient sleeps because the nurse could not assess the pain level.

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