- A nurse is caring for a client who has sustained burns over 37% of total body surface area. The client’s voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following?
a. Pulmonary edema
b. Bacterial pneumonia
c. Inhalation injury
d. Carbon monoxide poisoning (vasodilation will cause a cherry red appearance, treatment is high flow oxygen to pt.)
- A client in the intensive care unit (ICU) was recovering from moderate burns and smoke inhalation. His condition was improving, and plans were made to transfer him to a step-down unit. On the morning of the transfer, the client began to experience elevated temperatures and shortness of breath. Urine output decreased to 10ml/hr. Labs were drawn and indicated elevated white blood cells (WBC), glomerular filtration rate (GFR) creatinine, and liver enzymes. This client is experiencing which medical complication?
a. Disseminated Intravascular coagulation (DIC)
b. Acute respiratory failure (ARF)
c. Multiple organ dysfunction syndrome (MODS)
d. Acute kidney injury (AKI)
- A nurse is educating a new nurse on the different types of shock. The new nurse asked to identify which client is not experiencing distributive shock?
a. A client with septic-induced hypotension refractory to adequate fluid resuscitation b. A client with extensive spinal cord injury at T4 and a heart rate of 40 beats per minute
c. A client with an extreme type of allergic reaction to penicillin and stridor
d. A client with a tension pneumothorax and cardiovascular compression
- A nurse is managing several IV medications to maintain the blood pressure of a client in hypovolemic shock. Which medication places the client at risk for a hypertensive reaction requiring the nurse to assess the blood pressure at least every 15 minutes?
c. sodium nitroprusside
- A nurse is caring for a client who is in hypovolemic shock related to hemorrhage. The nurse prepares intravenous (IV) tubing to infuse with which IV solution in preparation for a blood transfusion?
a. 3% Sodium chloride solution
b. Total parenteral nutrition
c. Normal Saline solution (Blood can only be administered with NS)
d. Lactated Ringer’s solution
- A nurse is caring for a client who suffered a third-degree burn to his hands after a house fire. He presented with an airway injury secondary to smoke inhalation and has been intubated. The client is currently on the incubator with 100% FiO2. Based on this
information, which of the following would be a sign or symptom of acute respiratory distress syndrome (ARDS)?
a. Respiratory rate 14 breaths/minute
b. Arterial Blood Gas results show PaO2 50mmHg
c. Fatigue and weakness
d. Urine output 580 mL last shift
- The nurse is developing a care plan for a client in the acute phase of a burn injury. Which of the following would be the priority nurse diagnosis for this client?
a. Risk for falls r/t contracture of burned extremities
b. Risk for infection related to slow healing graft donor site
c. Risk for denial r/t inability to participate in dressing changes
d. Risk for ineffective coping r/t inability to look at burn wounds
- When assessing a client who has suffered a burn injury. The nurse classifies the burn as a superficial partial-thickness burn based