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final exam review
| Question | Answer |
|---|---|
| Which is considered an isotonic solution? | 0.9 Normal saline |
| An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? | Hypokalemia |
| With which condition should the nurse expect that a decrease in serum osmolality will occur? | Kidney failure |
| Which of the following is the most common cause of symptomatic hypomagnesemia in the United States? | Alcoholism |
| A priority nursing intervention for a client with hypervolemia involves which of the following? | Monitoring respiratory status for signs and symptoms of pulmonary complications |
| A client with respiratory acidosis is admitted to the intensive care unit for close observation. What client complication associated with respiratory acidosis would the nurse observe? | papilledema |
| The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer? | 0.45% sodium chloride |
| To confirm an acid–base imbalance, it is necessary to assess which findings from a client’s arterial blood gas (ABG) results? Select all that apply | pH PaCO2 HCO3 |
| A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported “dry mouth.” The nurse suspects the client is experiencing w | dehydration |
| Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? | Limit sodium and water intake. |
| The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? | Potassium: 5.8 mEq/L |
| A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3–), 24 mEq/L. Based | respiratory alkalosis. |
| A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3–), 15 mEq/L. These ABG values suggest which disorder? | Metabolic acidosis |
| A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 | Respiratory alkalosis |
| A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution? | Acidic |
| A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? | Light-headedness or paresthesia |
| Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area? | osmosis |
| Which of the following arterial blood gas results would be consistent with metabolic alkalosis? | Serum bicarbonate of 28 mEq/L |
| The nurse is caring for a patient with a metabolic acidosis (pH 7.25). Which of the following values is useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss? | Anion gap |
| A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? | Prepare to assist with ventilation. |
| A client with hypervolemia asks the nurse by what mechanism the sodium–potassium pump will move the excess body fluid. What is the nurse's best answer? | Active transport |
| Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? | Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad |
| A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse? | bicarbonate–carbonic acid buffer system |
| A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? | furosemide |
| Which electrolyte is a major cation in body fluid? | Potassium |
| Which electrolyte is a major anion in body fluid? | Chloride |
| Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: | muscle weakness. |
| In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? | A urine output consistently above 40 ml/hour |
| A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? | Gastric ulcers |
| A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? | 27% |
| When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area? | 1 |
| Which complication is common for victims of electrical burns? | Cardiac dysrhythmia |
| The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? | Skin grafting will be necessary. |
| The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient’s burns are full-thickness burns? | Identification by the destruction of the dermis and epidermis |
| Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? | Natural |
| A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-k | 2,400 mL |
| The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? | Music therapy may provide reality orientation, distraction, and sensory stimulation |
| A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client | Fluid resuscitation |
| A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? | Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. |
| Which antimicrobials is commonly used to treat burns? | Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution |
| When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? | ineffective airway clearance related to edema of the respiratory passages |
| A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. What depth of burn injury does the client have? | full thickness (third degree) |
| Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? | Reduction in blood volume |
| The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? | Roll the client in a blanket. |
| When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn? | Use client’s palm size |
| The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? | Preexisting conditions |
| Which of the following is to be expected soon after a major burn? Select all that apply | Hypotension, Tachycardia, Anxiety |
| Which is the primary reason for placing a client in a horizontal position while smothering flames are present? | To keep fire and smoke from airway |
| Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? | Deep partial-thickness |
| The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs im | Hyperkalemia |
| A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the aff | escharotomy |
| When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? | Hoarseness of the voice |
| The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? | Sulfadiazine, silver (Silvadene) |
| Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This | stasis. |
| A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? | Irrigate the wounds with water |
| A child tips a pot of boiling water onto his bare legs. The mother should | Immerse the child's legs in cool water. |
| A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include | premedicating the client with an analgesic prior to application. |
| The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to | decrease catabolism. |
| The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote | decreased catabolism. |
| A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? | Homografts |
| A client has been burned significantly in a workplace accident. Which conditions create the need for immediate intensive care by specifically trained personnel? Select all that apply. | Fluid loss Fluid shift Hypotension |
| Burn shock is characterized by which of the following? | Capillary leak |
| A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? | Urine output of 20 ml/hour |
| A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first? | Administer an epinephrine injection as ordered by the health care provider. |
| When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) | Urinary output Mental status Vital signs |
| A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nu | ondansetron |
| Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: | Blood pressure. |
| Which type of shock is caused by an infection? | Septic |
| Elevating the patient’s legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? | Head injury |
| The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? | 70% |
| The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client’s condition is in its initial stages? | A rapid, bounding pulse |
| The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? | Low |
| The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this pati | Disseminated intravascular coagulation (DIC) |
| The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? | It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. |
| What is the major clinical use of dobutamine? | increase cardiac output |
| A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess | Lung sounds |
| The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? | Adrenergic drugs |
| A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? | compensatory respiratory alkalosis |
| When vasoactive medications are administered, the nurse must monitor vital signs at least how often? | 15 minutes |
| The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? | WBC: 42,000/mm3 |
| Which drug is a vasodilator used in the treatment of shock? | Nitroglycerin |
| At what point in shock does metabolic acidosis occur? | Decompensation (Progressive) |
| A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: | Jugular venous distention |
| During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? | Brain |
| A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? | Intubation and mechanical ventilation |
| The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? | Narrowed pulse pressure |
| A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next | Administers oxygen by nasal cannula at 2 liters per minute |
| A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? | Modified Trendelenburg because it promotes the return of venous blood. |
| The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock? | Distributive |
| Three types of distributive shock are | neurogenic, septic, and anaphylactic shock |
| You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? | In the compensation stage, catecholamines are released. |
| The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? | Arterial blood gas (ABG) findings |
| The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? | Septic |
| The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body? | Production of antidiuretic hormone and corticosteroid hormones. Both ADH and corticosteroid hormones promote fluid re absorption and retention. |
| A nurse is evaluating a client’s drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure? | low urine output. When a MAP falls below 65 mm Hg, a client with progressive shock will have decreased kidney function and low urine output |
| You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? | In the compensation stage, catecholamines are released. activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. |
| When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention | Aorta |
| A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client’s condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? | Organ damage |
| The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in? | Progressive |
| The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? | Increase in arterial oxygenation |
| Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. | Famotidine (Pepcid) Nizatidine Lansoprazole |
| What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. | Assess the client who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs. |
| A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits | Adventitious breath sounds |
| A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers | A continuous infusion of total parenteral nutrition |
| What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client? | Decreased blood pressure. |
| A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock? | HR, 48 bpm; BP, 90/60 mm Hg |
| Which of the following clinical manifestations occur in cardiogenic shock? | Blood pressure falls |
| In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? | Nitroprusside |
| A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock? | A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. |
| The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? | Administer norepinephrine as prescribed. |
| A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. | kidney failure disseminated intravascular coagulation acute respiratory distress syndrome |
| The nurse is caring for a client in the compensation stage of shock. The nurse knows that one of the body’s mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do? | Restores blood pressure |
| The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate? | 3:1 |
| Clinical characteristics of neurogenic shock are noted by which type of stimulation? | Parasympathetic |
Created by:
shanise909