NUB 440_Critical_Care_Nursing_7th_Sole_TestBank_2016 - Marian University | NUB440_Critical_Care_Nursing_7th_Sole_TestBank_2016

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NUB 440_Critical_Care_Nursing_7th_Sole_TestBank_2016 - Marian University Table of Contents 1 Chapter 01: Overview of Critical Care Nursing Chapter 02: Patient and Family Response to the Critica... l Care Experience Chapter 03: Ethical and Legal Issues in Critical Care Nursing Chapter 04: Palliative and End-of-Life Care Chapter 05: Comfort and Sedation Chapter 06: Nutritional Therapy Chapter 07: Dysrhythmia Interpretation and Management Chapter 08: Hemodynamic Monitoring Chapter 09: Ventilatory Assistance Chapter 10: Rapid Response Teams and Code Management Chapter 11: Organ Donation Chapter 12: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Chapter 13: Cardiovascular Alterations Chapter 14: Nervous System Alterations Chapter 15: Acute Respiratory Failure Chapter 16: Acute Kidney Injury Chapter 17: Gastrointestinal Alterations Chapter 17: Hematological and Immune Disorders Chapter 19: Endocrine Alterations Chapter 20: Trauma and Surgical Management Chapter 21: Burns Chapter 01: Overview of Critical Care Nursing MULTIPLE CHOICE 1. Which of the following professional organizations best supports critical care nursing practice? a. American Association of Critical-Care Nurses b. American Heart Association c. American Nurses Association d. Society of Critical Care Medicine ANS: A The American Association of Critical-Care Nurses is the specialty organization that supports and represents critical care nurses. The American Heart Association supports cardiovascular initiatives. The American Nurses Association supports all nurses. The Society of Critical Care Medicine represents the multiprofessional critical care team under the direction of an intensivist. DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 2. A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for her to seek? a. ACNPC b. CCNS c. CCRN d. PCCN ANS: C The CCRN certification is appropriate for nurses in bedside practice who care for critically ill patients. The ACNPC certification is for acute care nurse practitioners. The CCNS certification is for critical care clinical nurse specialists. The PCCN certification is for staff nurses working in progressive care, intermediate care, or step-down unit settings. DIF: Cognitive Level: Application REF: p. 5 OBJ: Explain certification options for critical care nurses. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 3. The main purpose of certification is to: a. assure the consumer that you will not make a mistake. b. prepare for graduate school. c. promote magnet status for your facility. d. validate knowledge of critical care nursing. ANS: D Certification assists in validating knowledge of the field, promotes excellence in the profession, and helps nurses to maintain their knowledge of critical care nursing. Certification helps to assure the consumer that the nurse has a minimum level of knowledge; however, it does not ensure that care will be mistake-free. Certification does not prepare one for graduate school; however, achieving certification demonstrates motivation for achievement and professionalism. Magnet facilities are rated on the number of certified nurses; however, that is not the purpose of certification. DIF: Cognitive Level: Analysis REF: pp. 4-5 OBJ: Explain certification options for critical care nurses. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 4. The synergy model of practice focuses on: a. allowing unrestricted visiting for the patient 24 hours each day. b. holistic and alternative therapies. c. needs of patients and their families, which drives nursing competency. d. patients needs for energy and support. ANS: C The synergy model of practice states that the needs of patients and families influence and drive competencies of nurses. Nursing practice based on the synergy model would involve tailored visiting to meet the patients and familys needs and application of alternative therapies if desired by the patient, but that is not the primary focus of the model. DIF: Cognitive Level: Application REF: p. 5 | Fig. 1-3 OBJ: Describe standards of professional practice for critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 5. The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours and they have some questions that they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which competency of critical care nursing does this represent? a. Advocacy and moral agency in solving ethical issues b. Clinical judgment and clinical reasoning skills c. Collaboration with patients, families, and team members d. Facilitation of learning for patients, families, and team members ANS: C Although one might consider that all of these competencies are being addressed, communication and collaboration with the family and physician best exemplify the competency of collaboration. DIF: Cognitive Level: Analysis REF: p. 9 OBJ: Describe standards of professional practice for critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 6. The AACN Standards for Acute and Critical Care Nursing Practice use what framework to guide critical care nursing practice? a. Evidence-based practice b. Healthy work environment c. National Patient Safety Goals d. Nursing process ANS: D The AACN Standards for Acute and Critical Care Nursing Practice delineate the nursing process as applied to critically ill patients: collect data, determine diagnoses, identify expected outcomes, develop a plan of care, implement interventions, and evaluate care. AACN promotes a healthy work environment, but this is not included in the Standards. The Joint Commission has established National Patient Safety Goals, but these are not the AACN Standards. DIF: Cognitive Level: Analysis REF: p. 5 | Box 1-2 OBJ: Describe standards of professional practice for critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 7. The charge nurse is responsible for making the patient assignments on the critical care unit. She assigns the experienced, certified nurse to care for the acutely ill patient with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. She assigns the nurse with less than 1 year of experience to two patients who are more stable. This assignment reflects implementation of the: a. crew resource management model b. National Patient Safety Goals c. Quality and Safety Education for Nurses (QSEN) model d. synergy model of practice ANS: D This assignment demonstrates nursing care to meet the needs of the patient. The synergy model notes that the nurse competencies are matched to the patient characteristics. Crew resource management concepts related to team training, National Patient Safety Goals are specified by The Joint Commission to promote safe care but do not incorporate the synergy model. The Quality and Safety Education for Nurses initiative involves targeted education to undergraduate and graduate nursing students to learn quality and safety concepts. DIF: Cognitive Level: Analysis REF: p. 5 | Fig. 1-3 OBJ: Describe standards of professional practice for critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 8. The vision of the American Association of Critical-Care Nurses is a healthcare system driven by: a. a healthy work environment. b. care from a multiprofessional team under the direction of a critical care physician. c. the needs of critically ill patients and families. d. respectful, healing, and humane environments. ANS: C The AACN vision is a healthcare system driven by the needs of critically ill patients and families where critica care nurses make their optimum contributions. AACN promotes initiatives to support a healthy work environment as well as respectful and healing environments, but that is not the organizations vision. The SCCM promotes care from a multiprofessional team under the direction of a critical care physician. DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 9. The most important outcome of effective communication is to: a. demonstrate caring practices to family members. b. ensure that patient teaching is done. c. meet the diversity needs of patients. d. reduce patient errors. ANS: D Many errors are directly attributed to faulty communication. Effective communication has been identified as an essential strategy to reduce patient errors and resolve issues related to patient care delivery. Communication may demonstrate caring practices, be used for patient/family teaching, and address diversity needs; however, the main outcome of effective communication is patient safety. DIF: Cognitive Level: Knowledge REF: pp. 8-9 OBJ: Describe quality and safety initiatives related to critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 10. You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with the following report. Dr. Smith, Im calling about Mrs. P., your 65-year-old patient in CCU 10. Her urine output for the past 2 hours totaled only 40 mL. She arrived from surgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and her blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusion of normal saline at 100 mL per hour. Her right atrial pressure through the subclavian central line is low at 3 mm Hg. Her urine is concentrated. He BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider increasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patients history and vital signs is: a. Situation b. Background c. Assessment d. Recommendation ANS: B The history and vital signs are part of the background. Information regarding the low urine output is the situation. Information regarding possible hypovolemia is part of the nurses assessment, and the suggestion for fluids is the recommendation. DIF: Cognitive Level: Analysis REF: pp. 8-9 OBJ: Describe quality and safety initiatives related to critical care nursing. TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 11. The family members of a critically ill, 90-year-old patient bring in a copy of the patients living will to the hospital, which identifies the patients wishes regarding health care. You discuss contents of the living will with the patients physician. This is an example of implementation of which of the AACN Standards of Professional Performance? a. Acquires and maintains current knowledge of practice b. Acts ethically on the behalf of the patient and family c. Considers factors related to safe patient care d. Uses clinical inquiry and integrates research findings in practice ANS: B Discussing end-of-life issues is an example of a nurse acting ethically on behalf of the patient and family. The example does not relate to acquiring knowledge, promoting patient safety, or using research in practice. DIF: Cognitive Level: Analysis REF: p. 5 | Box 1-2 OBJ: Describe standards of care and performance for critical care nursing. TOP: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research? a. Clinical practice guidelines b. Computerized physician order entry c. Consulting with advanced practice nurses d. Implementing Joint Commission National Patient Safety Goals ANS: A Clinical practice guidelines are being implemented to ensure that care is appropriate and based on research. Some physician order entry pathways, but not all, are based on research recommendations. Some advanced practice nurses, but not all, are well versed in evidence-based practices. The National Patient Safety Goals are recommendations to reduce errors using evidence-based practices. DIF: Cognitive Level: Analysis REF: p. 7 OBJ: Describe standards of professional practice for critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 13. Comparing the patients current (home) medications with those ordered during hospitalization and communicating a complete list of medications to the next provider when the patient is transferred within an organization or to another setting are strategies to: a. improve accuracy of patient identification. b. prevent errors related to look-alike and sound-alike medications. c. reconcile medications across the continuum of care. d. reduce harms associated with administration of anticoagulants. ANS: C These are steps recommended in the National Patient Safety Goals to reconcile medications across the continuum of care. Improving accuracy of patient identification is another National Patient Safety Goal. Preventing errors related to look-alike and sound-alike medications is done to improve medication safety, not medication reconciliation. Reducing harms associated with administration of anticoagulants is another Nationa Patient Safety Goal. DIF: Cognitive Level: Comprehension REF: p. 6 | Box 1-3 OBJ: Describe quality and safety initiatives related to critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 14. As part of nursing management of a critically ill patient, orders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often called a: a. bundle of care. b. clinical practice guideline. c. patient safety goal. d. quality improvement initiative. ANS: A A group of evidence-based interventions done as a whole to improve outcomes is termed a bundle of care. This is an example of the ventilator bundle. Oftentimes these bundles are derived from clinical practice guidelines and are monitored for compliance as part of quality improvement initiatives. At some point, these may become part of patient safety goals. DIF: Cognitive Level: Analysis REF: p. 6 OBJ: Describe quality and safety initiatives related to critical care nursing. TOP: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. You work in an intermediate care unit that has experienced high nursing turnover. The nurse manager is often considered to be an autocratic leader by staff members and her leadership style is contributing to turnover. You have asked to be involved in developing new guidelines to prevent pressure ulcers in your patient population. The nurse manager tells you that you do not yet have enough experience to be on the prevention task force. This situation and setting is an example of: a. a barrier to handoff communication. b. a work environment that is unhealthy. c. ineffective decision making. d. nursing practice that is not evidence-based. ANS: B These are examples of an unhealthy work environment. A healthy work environment values communication, collaboration, and effective decision making. It also has authentic leadership. It is not an example of handoff communication, which is communication that occurs to transition patient care from one staff member to another. Neither does it relate to ineffective decision making. As a nurse, you can still implement evidence- based practice, but your influence in the unit is limited by the unhealthy work environment. DIF: Cognitive Level: Analysis REF: p. 7 OBJ: Describe standards of professional practice for critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 16. Which of the following statements describes the core concept of the synergy model of practice? a. All nurses must be certified in order to have the synergy model implemented. b. Family members must be included in daily interdisciplinary rounds. c. Nurses and physicians must work collaboratively and synergistically to influence care. d. Unique needs of patients and their families influence nursing competencies. ANS: D The synergy model of practice is care based on the unique needs and characteristics of the patient and family members. Although critical care certification is based on the synergy model, the model does not specifically address certification. Inclusion of family members into the daily rounds is an example of implementation of the synergy model. With the focus on patients and family members with nurse interaction, the synergy model does not address physician collaboration. DIF: Cognitive Level: Application REF: p. 5 | Fig. 1-3 OBJ: Describe standards of professional practice for critical care nursing. TOP: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17. A nurse who plans care based on the patients gender, ethnicity, spirituality, and lifestyle is said to: a. be a moral advocate. b. facilitate learning. c. respond to diversity. d. use clinical judgment. ANS: C Response to diversity considers all of these aspects when planning and implementing care. A moral agent helps resolve ethical and clinical concerns. Consideration of these factors does not necessarily facilitate learning. Clinical judgment uses other factors as well. DIF: Cognitive Level: Comprehension REF: p. 3 | Box 1-1 OBJ: Describe standards of professional practice for critical care nursing. TOP: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Which of the following is a National Patient Safety Goal? (Select all that apply.) a. Accurately identify patients. b. Eliminate use of patient restraints. c. Reconcile medications across the continuum of care. d. Reduce risks of healthcare-acquired infection. ANS: A, C, D All except for eliminating use of restraints are current National Patient Safety Goals. Hospitals have policies regarding use of restraints and are attempting to reduce the use of restraints; however, this is not a National Patient Safety Goal. DIF: Cognitive Level: Analysis REF: p. 6 | Box 1-3 OBJ: Describe quality and safety initiatives related to critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is (are) official journal(s) of the American Association of Critical-Care Nurses? (Select all that apply.) a. American Journal of Critical Care b. Critical Care Clinics of North America c. Critical Care Nurse d. Critical Care Nursing Quarterly ANS: A, C American Journal of Critical Care and Critical Care Nurse are two official AACN publications. Critical Care Clinics and Critical Care Nursing Quarterly are not AACN publications. DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 3. The first critical care units were: (Select all that apply.) a. burn units. b. coronary care units c. recovery rooms. d. neonatal intensive care units. ANS: B, C Recovery rooms and coronary care units were the first units designated to care for critically ill patients. Burn and neonatal intensive care units were established as specialty units evolved. DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: Define critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 4. Which of the following nursing activities demonstrates implementation of the AACN Standards of Professional Performance? (Select all that apply.) a. Attending a meeting of the local chapter of the American Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught b. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family c. Participating on the units nurse practice council d. Posting an article from Critical Care Nurse on management of venous thromboembolism for your colleagues to read e. Using evidence-based strategies to prevent ventilator-associated pneumonia ANS: A, B, C, D, E All answers are correct. Attending a program to learn about sepsisAcquires and maintains current knowledge and competency in patient care. Collaborating with pastoral servicesCollaborates with the healthcare team to provide care in a healing, humane, and caring environment. Posting information for othersContributes to the professional development of peers and other healthcare providers. Nurse practice councilProvides leadership in the practice setting. Evidence-based practicesUses clinical inquiry in practice. DIF: Cognitive Level: Analysis REF: p. 5 | Box 1-2 OBJ: Describe standards of professional practice for critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 5. Which scenarios contribute to effective handoff communication at change of shift? (Select all that apply.) a. The nephrology consultant physician is making rounds and asks you to update her on the patients status and assist in placing a central line for hemodialysis. b. The noise level is high because twice as many staff members are present and everyone is giving report in the nurses station. c. The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers. d. You and the oncoming nurse conduct a standardized report at the patients bedside and review key assessment findings. ANS: C, D A reporting tool and bedside report improve handoff communication by ensuring standardized communication and review of assessment findings. Conducting report at the bedside also reduces noise that commonly occurs at the nurses station during a change of shift. The nephrologist has created an interruption that can impede handoff with the next nurse. Likewise, noise in the nurses station can cause distractions that can impair concentration and listening. DIF: Cognitive Level: Analysis REF: p. 8-9 OBJ: Describe quality and safety initiatives related to critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 6. Which strategy is important to addressing issues associated with the aging workforce? (Select all that apply.) a. Allowing nurses to work flexible shift durations b. Encouraging older nurses to transfer to an outpatient setting that is less stressful c. Hiring nurse technicians that are available to assist with patient care, such as turning the patient d. Remodeling patient care rooms to include devices to assist in patient lifting ANS: A, C, D Modifying the work environment to reduce physical demands is one strategy to assist the aging workforce. Examples include overhead lifts to prevent back injuries. Twelve-hour shifts can be quite demanding; therefore, allowing nurses flexibility in choosing shifts of shorter duration is a good option as well. Adequate staffing, including non-licensed assistive personnel, to help with nursing and non-nursing tasks is helpful. Encouraging experienced, knowledgeable critical care nurses to leave the critical care unit is not wise as the unit loses the expertise of this group. DIF: Cognitive Level: Analysis REF: p. 11 OBJ: Identify current trends and issues in critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -1. The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is: a. altered nutrition, less than body requirements. b. body image disturbance. c. decreased cardiac output. d. fluid volume deficit. ANS: B Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result. Nutritional support is started early in management of the patient with burns, and there is no indication that this patient has a nutritional deficit. Nursing care plan priorities would also continue to focus on nutritional needs to optimize healing. Decreased cardiac output and fluid volume deficit should not be priority concerns during the wound closure phase of burn wound management by grafting. DIF: Cognitive Level: Application REF: p. 650 OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2. The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurses knowledge of nutritional goals? a. Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal. b. Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal. c. It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster. d. Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing. ANS: B Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body. DIF: Cognitive Level: Application REF: p. 650 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for: a. acute delirium. b. posttraumatic stress disorder. c. suicidal intentions. d. bipolar disorder. ANS: B Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients that demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder. Acute delirium is more likely to occur during the acute phase of injury. Suicidal ideations should always be addressed if the patient expresses or shows signs of suicidal thoughts. Burn-injured patients may have an underlying mental health disorder that requires treatment, such as bipolar disorder or schizophrenia. DIF: Cognitive Level: Application REF: pp. 650-651 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is planning care to meet the patients pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurses knowledge of pain management for this patient? a. Can we ask the music therapist to come by each morning to see if that will help the patients pain? b. The patients pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock. c. The patients pain is often unrelieved. It would be best if we can schedule the opioids around the clock. d. The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better? ANS: D Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing independence with pain management strategies. Nonpharmacological pain strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put the control of pain management with the patient. DIF: Cognitive Level: Application REF: pp. 642-643 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5. The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a. Do you live alone? b. Do you have any drug or food allergies? c. Do you have a heart condition or heart failure? d. Have you had any surgeries? ANS: C Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutrition status, and comorbid diseases, especially heart failure. Assessment questions should include, as a priority, information about the patients cardiovascular status, including heart failure. Obtaining food or drug allergy information is also important along with other past medical history, including past surgeries. Information on the patients living arrangements is an important safety consideration for discharge planning. DIF: Cognitive Level: Application REF: p. 652 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible nonburn injured skin disorder? a. Toxic epidermal necrolysis b. Staphylococcal scalded skin syndrome c. Necrotizing soft tissue infection d. Graft versus host disease ANS: A Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present with acute onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours, skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury. Staphylococcal scalded skin syndrome presents predominantly in children. Necrotizing soft tissue infection results from rapidly invasive bacterial infections. Graft versus host disease is not logical given the clinical information provided. DIF: Cognitive Level: Comprehension REF: pp. 652-653 OBJ: Review the anatomy and physiology of the integumentary system. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. A(An) often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a. chemical burn b. electrical burn c. heat burn d. infection ANS: B Tissue damage results from the conversion of electrical energy into heat. Monitor the patient for cardiac dysrhythmias. DIF: Cognitive Level: Comprehension REF: pp. 616-617 OBJ: Describe the pathophysiology of burns. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration. ANS: A, B, C The rapid metabolism associated with burn injury may require additional pain medication. Many of the procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication should be given prior to the procedures. Edema in burned patients alters the absorption of medications that are injected intramuscularly; therefore, drugs must be administered by the IV route. DIF: Cognitive Level: Application REF: pp. 644-645 OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. Which of the following factors increase the burn patients risk for venous thromboembolism? (Select all that apply.) a. Burn injury less than 10% b. Bedrest c. Burns to lower extremities d. Electrical burn injury e. Delayed fluid resuscitation ANS: B, C, E Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bedrest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA. DIF: Cognitive Level: Application REF: p. 638 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages ANS: A, B, D It is important to avoid immobility in patients with burns of the hands, feet, or major joints. Measures must be taken to maintain the function of the hands, feet, and major joints. Nursing interventions to maintain range of motion, applying splits to keep the extremities in a position of function, and individually wrapping fingers and toes are necessary to maintain function of the hands, feet, and joints. Effective pain management is necessary to encourage mobility. DIF: Cognitive Level: Application REF: p. 641 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management. ANS: A, C, E Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and restricting family is not an intervention related to infection prevention. DIF: Cognitive Level: Application REF: pp. 643-644 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Which complications may manifest after an electrical injury? (Select all that apply.) a. Long bone fractures b. Cardiac dysrhythmias c. Hypertension d. Compartment syndrome of extremities e. Dark brown urine f. Peptic ulcer disease g. Acute cataract formation h. Seizures ANS: A, B, D, E, G, H Electrical injuries vary in severity of injury by the intensity of energy exposed to the body. Manifestations and complications may include cardiac dysrhythmias or cardiopulmonary arrest, hypoxia, deep tissue necrosis, rhabdomyolysis and acute kidney injury, compartment syndrome, long bone fractures, acute cataract formation, and neurological deficits (including seizures). Hypertension and peptic ulcer disease are not direct consequences of electrical burn injuries. DIF: Cognitive Level: Application REF: Box 20-2 OBJ: Compare types of burn injuries. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.) a. involves a joint. b. involves the face, hands, or feet. c. is infected. d. requires more than 2 weeks for healing. ANS: A, B, D Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization. DIF: Cognitive Level: Comprehension REF: p. 647 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The correct priority order of actions in prehospital primary survey for burn injuries is: , , , . (Put a comma and space between each answer choice.) a. Assess ABCs and cervical spine. b. Provide oxygen therapy if smoke inhalation is suspected. c. Make rapid head-to-toe assessment to rule out additional trauma. d. Stop the burning process and prevent further injury. ANS: D, A, B, C Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries. DIF: Cognitive Level: Analysis REF: p. 632 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. 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