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NURS_2140 Exam 3: Burns and Shock
Terms in this set (62)
___% of patients who smoke, will light themselves on fire
coordinated national burn programs include...
child-resistant lighters, nonflammable children's clothing, tap water anti-scald devices, fire-safe cigarettes, stricter building codes, hard-wired smoke detectors/alarms, and fire sprinklers
MOST COMMON BURN INJURY; flash, flame, or contact burns that can occur while cooking, smoking, burning leaves in the backyard, or through misuse of gasoline or hot oil
Always maintain the hot water heater to ___ degrees
first degree burn; involves only the epidermis, the outer layer of the skin. Characterized by reddening of the skin and some swelling; sunburn
partial thickness burn
2nd degree burn; damage to the entire epidermis and varying depths of the dermis.
deep partial thickness burn
2nd degree burn; red to white, moderate edema, severe pain (bc hitting vascular nerve area), fluid filled vesicles, shiny and wet, beyond surface but not beyond tissues
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry,
pale, and hard skin. The patient states that the burn is not painful. What term would the nurse
use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction
with full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction.
On admission to the burn unit, a patient with an approximate 25% total body surface area
(TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L),
serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority?
a. Monitoring urine output every 4 hours.
b. Continuing to monitor the laboratory results.
c. Increasing the rate of the ordered IV solution.
d. Typing and crossmatching for a blood transfusion.
the patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased.
Normal Hgb level in women is?
normal hgb level in men
Normal Hct values
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially,
wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are
audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.
the patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately so that intubation can be done rapidly.
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland
formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The
initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
a. 219 mL/hr
b. 625 mL/hr
c. 938 mL/hr
d. 1875 mL/hr
half of the fluid replacement using the parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.
when fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss.
patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To
maintain adequate nutrition, the nurse should plan to take which action?
a. Administer vitamins and minerals intravenously.
b. Insert a feeding tube and initiate enteral feedings.
c. Infuse total parenteral nutrition via a central catheter.
d. Encourage an oral intake of at least 5000 kcal per day.
enteral feedings can usually be started 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 nutrition absorption. Parenteral nutrition increases the infection risk, and does not help preserve GI function.
While the patient's full-thickness burn wounds to the face are exposed, what nursing action
prevents cross contamination?
a. Use sterile gloves when removing dressings.
b. Wear gown, cap, mask, and gloves during care.
c. Keep the room temperature at 70° F (20° C) at all times.
d. Give IV antibiotics to prevent bacterial colonization of wounds.
use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. Room temperature should be kept at 85 F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the fingers.
c. Assist the patient to a supine position with a small pillow under the head.
d. Position the patient in a side-lying position with rolled towel under the neck.
the right hand and arm should be elevate to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears.
Burn patients with neck burns should not use a pillow or rolled towel because the head should be maintained in an ___ position in order to avoid ___
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse
strength and numbness in the toes. Which action should the nurse take first?
a. Monitor the pulses every hour.
b. Notify the health care provider.
c. Elevate both legs above heart level with pillows.
d. Encourage the patient to flex and extend the toes.
the decrease in pulse and numbness in a patient with circumferential burns indicates decreased circulation to the legs ad the need for an escharotomy. Elevating the legs or increasing toe movement will not improve the patient's circulation
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?
a. Bowel sounds
b. Stool frequency
c. Stool occult blood
d. Abdominal distention
H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has sustained burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite
which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns?
a. ketorolac (Toradol)
b. lorazepam (Ativan)
c. gabapentin (Neurontin)
d. hydromorphone (Dilaudid)
opioid pain medications are the best choice for pain control. The other drugs are adjuvants to enhance the effects of opioids
young adult patient who is in the rehabilitation phase after having deep partial-thickness
face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving?
a. "I'm glad the scars are only temporary."
b. "I will avoid using a pillow, so my neck will be OK."
c. "Do you think dark beige makeup will cover this scar?"
d. "I don't think my boyfriend will want to look at me now."
the willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scares indicates a willingness to discuss appearance but not resolution of the problem. Deep partial thickness burns leave permanent scars, not temporary.
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function?
a. Monitor white blood cells (WBCs).
b. Continue to measure the urine output.
c. Assess that blisters and edema have subsided.
d. Encourage the patient to eat an adequate number of calories.
the patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of
burn treatment. Which snack would be best for the nurse to offer to this patient?
b. Orange gelatin
c. Vanilla milkshake
d. Whole grain bagel
a patient with a burn injury needs high-protein and high-calorie food intake, and the milkshake Is the highest in these nutrients. The other choices are not as nutrient dense as the milkshake.
A patient has just arrived in the emergency department after an electrical burn from exposure
to a high-voltage current. What is the priority nursing assessment?
a. Oral temperature
b. Peripheral pulses
c. Extremity movement
d. Pupil reaction to light
all patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.
An employee spills industrial acids on both arms and legs at work. What action should the
occupational health nurse take first?
a. Remove nonadherent clothing and wristwatch.
b. Apply an alkaline solution to the affected area.
c. Place a cool compress on the area of exposure.
d. Cover the affected area with dry, sterile dressings.
with chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if the face was exposed). Flush the chemical from the wound and surrounding area with copious amounts of saline solution or water. Application of alkaline solution is not recommended.
A patient who has burns on the arms, legs, and chest from a house fire has become agitated
and restless 8 hours after being admitted to the hospital. Which action should the nurse take
a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check oxygen saturation.
agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain.
A patient arrives in the emergency department with facial and chest burns caused by a house
fire. Which action should the nurse take first?
a. Auscultate the patient's lung sounds.
b. Determine the extent and depth of the burns.
c. Give the prescribed hydromorphone (Dilaudid).
d. Infuse the prescribed lactated Ringer's solution.
a patient with facial and chest burns is at risk for inhalation injury and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?
a. Assess pain level.
b. Place on heart monitor.
c. Check potassium level.
d. Assess oral temperature.
after an electrical burn, the patient is at risk for life-threatening dysrhythmias and should be placed on a heart monitor. Assessing the oral temperature and pain is not as important as assessing for cardiac dysrhythmias.
Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA),
the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would
be a priority to communicate to the health care provider?
a. Blood pressure is 95/48 per arterial line.
b. Urine output of 41 mL over past 2 hours.
c. Serous exudate is leaking from the burns.
d. Heart monitor shows sinus tachycardia of 108.
urine output should be at least 0.5-1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. BP during emergent phase should be greater than 90 mmhg systolic and the pulse rate should be less than 120 beats/min.
Which patient should the nurse assess first?
a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain
b. A patient with smoke inhalation who has wheezes and altered mental status
c. A patient with full-thickness leg burns who is scheduled for a dressing change
d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr
this patient has evidence of lower airway injury and hypoxemia, and should be assessed immediately to determine the need for O2 or intubation (or both). The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications
In which order will the nurse take these actions when doing a dressing change for a
partial-thickness burn wound on a patient's chest? (Put a comma and a space between each
answer choice [A, B, C, D, E].)
a. Apply sterile gauze dressing.
b. Document wound appearance.
c. Apply silver sulfadiazine cream.
d. Give IV fentanyl (Sublimaze).
e. Clean wound with saline-soaked gauze.
d, e, c, a, b
Because partial-thickness burns are very painful, the nurse's first action should be to give pain
medications. The wound will then be cleaned, antibacterial cream applied, and covered with a
new sterile dressing. The last action should be to document the appearance of the wound.
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the
burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate
(mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?
The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the remaining half
is given over 16 hours: 4 x 80 x 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8
hours; 4800 mL/8 hr = 600 mL/hr.
The nurse estimates the extent of a burn using the rule of nines for a patient who has been
admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What
percentage of the patient's total body surface area (TBSA) has been injured?
When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and the anterior (4.5%) and posterior (4.5%) left arm equals 9%.
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase
after a burn injury to the right arm and chest?
a. Keep the right arm in a position of comfort.
b. Avoid the use of sustained-release narcotics.
c. Teach about the purpose of tetanus immunization.
d. Apply water-based cream to burned areas frequently.
application of water-based emollients will moisturize new skin and decrease flaking and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Tetanus immunization would have been given during the emergent phase of the burn injury.
Which nursing action is a priority for a patient who has suffered a burn injury while working
on an electrical power line?
a. Inspect the contact burns.
b. Check the blood pressure.
c. Stabilize the cervical spine.
d. Assess alertness and orientation.
cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine take precedence after airway managements.
The charge nurse observes the following actions being taken by a new nurse on the burn unit.
Which action by the new nurse would require immediate intervention by the charge nurse?
a. The new nurse uses clean gloves when applying antibacterial cream to a burn
b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F
c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a
d. The new nurse calls the health care provider when a nondiabetic patient's serum
glucose is elevated.
sterile gloves should be used when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate.
syndrome characterized by decreased tissue perfusion and impaired cellular metabolism; imbalance in supply/demand for O2 and nutrients
what are the four stages of shock
initial, compensatory, progressive, refractory
stage of shock in which a cascade of organ and gland stimulation and hormones increases blood pressure, restores atrial wall tension, and maintains near normal blood pressure and perfusion of vital organs.
A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous
pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3
hours. Which order by the health care provider should the nurse question?
a. Administer furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Give hydrocortisone (Solu-Cortef) 100 mg IV.
d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg
furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock; patients with septic shock require large amounts of fluid replacement
A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of
92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure
(PAWP). Which intervention ordered by the health care provider should the nurse question?
a. Elevate head of bed to 30 degrees.
b. Infuse normal saline at 250 mL/hr.
c. Hold nitroprusside if systolic BP is less than 90 mm Hg.
d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.
The patient's elevated PAWP indicates volume excess in relation to cardiac pumping ability,
consistent with cardiogenic shock. A saline infusion at 250 mL/hr will exacerbate the volume
excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP.
A patient with massive trauma and possible spinal cord injury is admitted to the emergency
department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?
a. Inspiratory crackles
b. Heart rate 45 beats/min
c. Cool, clammy extremities
d. Temperature 101.2°F (38.4°C)
neurogenic shock is characterized by hypertension and bradycardia
An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring
indicates a high systemic vascular resistance (SVR). Which intervention should the nurse
a. Increase the rate for the dopamine infusion.
b. Decrease the rate for the nitroglycerin infusion.
c. Increase the rate for the sodium nitroprusside infusion.
d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion
nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output.
After receiving 2 L of normal saline, the central venous pressure for a patient who has septic
shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for
d. sodium nitroprusside
when fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP.
To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?
a. Auscultate bowel sounds.
b. Ask the patient about nausea.
c. Check stools for occult blood.
d. Palpate for abdominal tenderness.
proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients.
A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication?
a. 5% albumin infusion
b. furosemide (Lasix) IV
c. epinephrine (Adrenalin) drip
d. hydrocortisone (Solu-Cortef)
The pulmonary artery wedge pressure (PAWP) indicates that the patient's preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the rate and myocardial oxygen demand.
The emergency department (ED) nurse receives report that a seriously injured patient involved
in a motor vehicle crash is being transported to the facility with an estimated arrival in 5
minutes. In preparation for the patient's arrival, the nurse will obtain
a. a dopamine infusion.
b. a hypothermia blanket.
c. lactated Ringer's solution.
d. two 16-gauge IV catheters.
a patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities.
Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?
a. Hemoglobin is within normal limits.
b. Urine output is 65 mL over the past hour.
c. Central venous pressure (CVP) is normal.
d. Mean arterial pressure (MAP) is 72 mm Hg.
assessment of end organ perfusion, such as adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 ml/kg/hr.
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic
a. Check temperature every 2 hours.
b. Monitor breath sounds frequently.
c. Maintain patient in supine position.
d. Assess skin for flushing and itching.
because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently.
Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care
provider before starting the norepinephrine?
a. The patient is receiving low dose dopamine.
b. The patient's central venous pressure is 3 mm Hg.
c. The patient is in sinus tachycardia at 120 beats/min.
d. The patient has had no urine output since being admitted.
adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement
A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?
a. No new heart murmurs
b. Decreased troponin level
c. Warm, pink, and dry skin
d. Blood pressure of 92/40 mm Hg
warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside Is a vasodilator, the blood pressure may be low even if the drug is effective
Which assessment information is most important for the nurse to obtain when evaluating
whether treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
c. Blood pressure
d. Oxygen saturation
because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment.
The health care provider orders the following interventions for a 67-kg patient who has septic
shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which
order will the nurse implement the actions? (Put a comma and a space between each answer
choice [A, B, C, D, E].)
a. Give vancomycin 1 g IV.
b. Obtain blood and urine cultures
c. Start norepinephrine 0.5 mcg/min.
d. Infuse normal saline 2000 mL over 30 minutes.
e. Titrate oxygen administration to keep O2 saturation above 95%.
e, d, c, b, a
the initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics.
A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on the
infusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting the
infusion pump, the nurse will set the infusion rate at how many milliliters per hour?
To administer the dobutamine at the prescribed rate of 5 mcg/kg/min from a concentration of
250 mg in 250 mL, the nurse will need to infuse 27 mL/hr.
Which preventive actions by the nurse will help limit the development of systemic
inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that
a. Ambulate postoperative patients as soon as possible after surgery.
b. Use aseptic technique when manipulating invasive lines or devices.
c. Remove indwelling urinary catheters as soon as possible after surgery.
d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
e. Advocate for parenteral nutrition for patients who cannot take in adequate calories
a, b, c, d
Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as
removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early
ambulation should be included in the plan of care. Adequate nutrition is important in
preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are
unable to take oral feedings because enteral nutrition helps maintain the integrity of the
intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being
prescribed to decrease the risk of sepsis progressing to SIRS.
A patient with suspected neurogenic shock after a diving accident has arrived in the
emergency department. A cervical collar is in place. Which actions should the nurse take
(select all that apply)?
a. Prepare to administer atropine IV.
b. Obtain baseline body temperature.
c. Infuse large volumes of lactated Ringer's solution.
d. Provide high-flow O2 (100%) by nonrebreather mask.
e. Prepare for emergent intubation and mechanical ventilation.
a, b, d, e
All of the actions are appropriate except to give large volumes of lactated Ringer's solution.
The patient with neurogenic shock usually has a normal blood volume, and it is important not
to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all
shock situations because an ischemic liver cannot convert lactate to bicarbonate.
After change-of-shift report in the progressive care unit, who should the nurse care for first?
a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in
the lung bases
b. Patient with suspected urosepsis who has new orders for urine and blood cultures
c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate
of 54 beats/minute
d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and
a blood pressure of 108/58 mm Hg
Antibiotics should be given within the first hour for patients who have sepsis or suspected
sepsis in order to prevent progression to systemic inflammatory response syndrome and septic
shock. The data on the other patients indicate that they are more stable. Crackles heard only at
the lung bases do not require immediate intervention in a patient who has had a myocardial
infarction. Mild bradycardia does not usually require atropine in patients who have a spinal
cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of
bronchospasm and hypotension
Which finding about a patient who is receiving vasopressin to treat septic shock indicates an
immediate need for the nurse to report the finding to the health care provider?
a. The patient's urine output is 18 mL/hr.
b. The patient is complaining of chest pain.
c. The patient's peripheral pulses are weak.
d. The patient's heart rate is 110 beats/minute.
Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion.
The other information is consistent with the patient's diagnosis, and should be reported to the
health care provider but does not indicate an immediate need for a change in therapy.
The following interventions are ordered by the health care provider for a patient who has
respiratory distress and syncope after eating strawberries. Which will the nurse complete
a. Give epinephrine.
b. Administer diphenhydramine.
c. Start continuous ECG monitoring.
d. Draw blood for complete blood count (CBC)
Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the
effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release
that cause the symptoms of anaphylaxis.
patient who has neurogenic shock is receiving a phenylephrine infusion through a right
forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate
a. The patient's heart rate is 58 beats/min.
b. The patient's extremities are warm and dry.
c. The patient's IV infusion site is cool and pale.
d. The patient's urine output is 28 mL over the past hour.
The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The
nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical
pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need
for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to
monitor the output over the next hour, but an immediate change in therapy is not indicated.
Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a
change in therapy or immediate action.
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