NUR 2755 Multidimensional Care IV MDC 4 Rasmussen Exam 1 2024, Exams of Nursing

Download NUR 2755 Multidimensional Care IV MDC 4 Rasmussen Exam 1 2024 and more Exams Nursing in PDF only on Docsity! NUR 2755 Multidimensional Care IV MDC 4 Rasmussen Exam 1 2024 B. Evaluate airway and circulation. - The nurse is caring for a patient who is admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care? A. Assess and treat pain. B. Evaluate airway and circulation. C. Place two IV catheters and initiate fluid resuscitation. D. Use the rule of nines to estimate percent of body surface area burned. B. Notify the physician immediately. - It has been 12 hours since a patient has been admitted for burns to the face and neck with associated inhalation injuries. The patient had been wheezing audibly and the wheezing has now stopped. What nursing action is appropriate? A. Check the patient's Spo2 level. B. Notify the physician immediately. C. Re-assess breathing in 1 hour. D. Document improvement in patient's condition. D. Possible allergic reaction to silver sulfadiazine (Silvadene) - A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient's white blood cell count has dropped significantly over the past 4 days. How does the nurse interpret this finding? A. Electrolyte imbalance B. Infection is improving C. Impending kidney disease D. Possible allergic reaction to silver sulfadiazine (Silvadene) A. 24-year-old male admitted with blunt chest trauma and aspiration - Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)? A. 24-year-old male admitted with blunt chest trauma and aspiration B. 56-year-old male with a history of alcohol abuse and chronic pancreatitis C. 72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells D. 82-year-old female on antibiotics for pneumonia B. "I should eat more green leafy vegetables like spinach." - A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse? A. "I should limit my alcohol consumption." B. "I should eat more green leafy vegetables like spinach." C. "I should take the medication at the same time every day." D. "I should make a doctor's appointment for weekly blood draws." D. Opioid analgesic overdose - A patient in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential cause of ventilatory failure? A. Pulmonary edema B. Hypovolemic shock C. Pulmonary embolus D. Opioid analgesic overdose B. Initiate intravenous fluid resuscitation. - A 37-year-old male is admitted with a severely abscessed tooth, BP 90/42, HR 136, RR 28, Spo2 90% on room air, temperature 38.7º C. The nurse suspects that the patient has developed sepsis. What is the priority nursing intervention? A. Insert an indwelling urinary catheter. B. Initiate intravenous fluid resuscitation. C. Obtain a complete chemistry for laboratory analysis. D. Administer prescribed antibiotics prior to blood cultures. B. Increased heart rate - When assessing a patient for shock, the nurse knows that which symptom is the earliest manifestation of shock? A. Anuria B. Increased heart rate C. A decrease in respiratory rate and depth D. A change in both systolic and diastolic blood pressure D. Bleeding, oozing from IV sites - Which clinical manifestations does the nurse recognize that indicates worsening in the condition of a patient in the refractory phase of shock? A. Warm, flushed skin B. Urine output of 20 mL/hr C. Increasing respiratory rate D. Bleeding, oozing from IV sites *Diminished breath sounds* ▪ also asymmetry paradoxical chest movement = flail chest (when pt inhales the good side goes out and the bad side goes in, like a see saw)* fever = sepsis Prone High Fowler's Supine In the recovery position Hyperkalemia - The priority Nursing diagnosis during the Acute Phase of Burn injury include all except: Risk for infection Impaired Skin Integrity Nutrition: Less than body requirements Hyperkalemia Angioedema (this would be in burns or anaphylactic shock) remember neurogenic shock is LOW and SLOW - Clinical manifestation of neurogenic shock include all of the following except: Bradycardia Poikilothermia (inability to control temperature) Angioedema Hypotension Silver Sulfadiazine - used for wound care (debridement) - A client allergic to Sulfa should not receive: Vancomycin Atropine Furosemide Silver Sulfadiazine Stop the infusion - vasoconstrictors should be in a central line - The client receiving norepinephrine has a painful IV site. What should you do first? Continue to monitor Notify the Provider Document the finding Stop the infusion False - it indicates fluid volume excess! - An elevated Pulmonary Artery Wedge Pressure indicates fluid volume deficit. True False Crackles, SOB, Pink frothy sputum think left ("lung") sided heart failure s/s - Signs of Cardiogenic shock include: Crackles, SOB, Pink frothy sputum Low BP, Increase Temp, purulent drainage from a wound Low BP and Low HR Pallor, low H/H, and ALOC MONA inotropes: dobutamine, milrinone - remember cardiogenic shock is caused by MI - Treatment of cardiogenic shock CT angiogram - A Pulmonary Embolism can be diagnosed by: CT of the head CT angiogram Lumbar Puncture Blood Cultures False "MAP easy as 1,2,3" {(1xSBP) + (2xDBP)}/3 {(1x100) + (2x40)/3} = 60 - For a BP 100/40 the MAP is 75 True False Vasopressin administration - this is given for shock - The following are related to ARDS except: Refractory hypoxemia Vasopressin administration Non-cardiac pulmonary edema Prone Positioning and PEEP Increased thirst and decreased UO - MAP will drop 10* - MODS is late stage* - Hyperkalemia* - The client in the non-progressive stage of shock will have: Increased thirst and decreased UO Normal MAP MODS Hypokalemia Cardiogenic (pump failure) - distributive shock means fluid is in areas it doesn't belong - Which of the following is not a type of distributive shock? Anaphylactic Septic Cardiogenic Neurogenic cardiac tamponade r/t pericarditis clinical manifestations: distant heart sounds - #1 cause of obstructive shock Warfarin - A client with a DVT will be prescribed: Esomeprazole Warfarin Sildenafil Furosemide Needs skin grafting - A characteristic of full-thickness burn include: Very painful Heals without intervention Needs skin grafting Blisters develop True 30mL/kg 30mL x 80kg = 2,400mL - A client in septic shock is 80Kg. An appropriate fluid volume infusion would be 2400MLs of LR True False D-dimer - Which lab would the nurse anticipate for a patient with a pulmonary emboli? Sed rate Urinalysis CBC D-dimer True - A vena cava filter is one of the preventions used for patients with pulmonary emboli to prevent further PEs True False 0.9% NS - Which IV fluid is the best choice for a patient in hypovolemic shock? 0.45% Sodium Chloride 0.9% NS Dextrose 10% Lactated Ringers False - A patient with a tension pneumothorax and cardiovascular compression is at risk for distributive shock True False Increased MAP without change to vascular tone - Norepinephrine is often used for patients in distributive shock due to its ability to cause Increased MAP by increasing vascular tone Decreased MAP by decreasing vascular volume Decreased MAP from capillary leak Increased MAP without change to vascular tone *1,000 mL/hr* Use Parkland Formula: 4mL x TBSA% x kg 4mL x 55% x (160/2.2) = 16,000 divided by 2 = 8,000 mL in the first 8 hours...8,000mL/8 hr = 1,000mL/hr - TBSA 55%, Wt 160 lbs, what is the initial IV rate if the client arrived immediately after the injurt? 1000 mL/hr 800 mL/hr 750 mL/hr 1200 mL/hr A client who has a hemoglobin of 10.1 mg/dL post 1 unit PRBC - Which patient is at the lowest risk for developing ARDS? A client following coronary artery bypass graft surgery A client who has a hemoglobin of 10.1 mg/dL post 1 unit PRBC A client who experienced a near-drowning incident in freshwater A client who is experiencing acute pancreatitis and vomiting