Trauma/Sepsis/MODS/Burns NCLEX questions 2020

Trauma/Sepsis/MODS/Burns NCLEX questions 2020 ScienceMedicineEmergency Medicine vescuderorivera Save Skin Integrity & Wound Care - NCLE...21 terms P4542Preview NURS 342 Test #3 - Ch. 66 - Shock, ...19 terms ElliotReid7Preview Final Exam Near Drowning 17 terms ForTheLoveOfAir Preview Cancer 10 terms Kat A patient who was admitted to the emergency department after a gunshot wound to the chest is hemorrhaging. What interventions should the nurse anticipate? (Select all that apply.)

• Administration of IV vasopressors
• Initiation of IV access with two large-bore catheters
• Open resuscitative thoracotomy
• Administration of packed red blood cells
• Rapid administration of IV fluid

Answer: 2, 3, 4, 5

Rationales:

• IV vasopressors will not be administered until fluid resuscitation is achieved.
• IV access should be achieved with large-bore catheters to allow for rapid administration of blood or fluid.
• Open resuscitative thoracotomy may be done as a last resort to manage the bleeding structures within the chest.
• Blood and blood products will be administered to increase oxygen-carrying capacity.
• Intravascular fluid volume must be replaced. IV fluids are easily obtainable and can be administered quickly.

Which assessment would alert the nurse to the presence of a flail chest?

• Tachycardia
• Paradoxical chest wall movement
• Splinting
• Tachypnea

Answer: 2

Rationales:

• Tachycardia is related to numerous patient situations and is not specific to flail chest.
• Paradoxical chest wall movement occurs when a section of the chest wall is no longer attached to the underlying rib structure. This section

"floats" and moves in an opposite direction from the remainder of the chest wall. When the chest wall expands, this section retracts. This is a classic finding associated with flail chest.

• Splinting is related to any painful movement and is not specific to flail chest.
• Tachypnea is related to numerous patient situations and is not specific to flail chest.

A nurse is advised that a patient with multiple blunt trauma is expected to arrive in the emergency department. What preparations should the nurse make?

• Check the available supply of dressings and bandages.
• Stock the receiving room with suture kits.
• Prepare a chest tube drainage tray.
• Alert radiology staff that x-rays will be required.

Answer: 4

Rationales:

• Dressings and bandages are not the priority because skin integrity is not disturbed in blunt trauma.
• Blunt trauma is defined as an injury in which the skin integrity is not disturbed. If this patient's injuries are limited to blunt trauma, suture kits will

not be required.

• A chest tube drainage tray may be required, but it is not clear if that is the case in this situation.
• Because the forces of blunt trauma are transferred to the tissues involved, deformation is likely. Radiologic studies are necessary to determine

the presence of broken bones and other injuries.A patient presents to the Emergency Department with a branch impaled in his arm. What nursing actions are indicated? Select all that apply.

1.Prevent the patient from removing the object.

2.Remove the branch with slow, steady pressure.

3.Remove the branch quickly.

4.Stabilize the object with padding.

answers:

1.Prevent patient from removing the object 4.stabilizing the object with padding Rationale The patient may attempt to remove the impaled object. The nurse should prevent this from occurring.The object should be stabilized with padding until further examination A patient has an open pneumothorax. Which nursing actions are indicated? Select all that apply.

1.place an occlusive dressing over the wound 2.Leave the bottom of the dressing untaped 3.Cover the area with a light covering of sterile gauze

• Pack the wound with saline-soaked gauze

Correct 1.Place an occlusive dressing over the wound 2.Leave the bottom of the dressing untapped Rationale An occlusive dressing will restrict the amount of free air entering the chest cavity.Leaving the bottom of the dressing untaped allows air to escape from the chest cavity if pressure increases.

A patient has hypovolemic shock as a result of massive gastrointestinal bleeding. The patient is given fluids and vasopressors. Which outcome indicates to the nurse that these treatments are having the desired effect?

• Urine output is normal.
• Base deficit is -6 mmol.
• Blood pressure is now 90/60 mm Hg.
• Lactate levels are decreasing from admission levels.

Answer: 4

Rationales:

• Using urine output as a marker of resuscitation may provide a false sense of security because the urine output may be related to

neuroendocrine response.

• A base deficit of -6 mmol indicates that moderate shock is persisting.
• Shock can persist despite "normalization" of blood pressure. This BP may be normal for one patient and hypotensive for another.
• Serum lactate levels can be used as an indirect measure of impaired oxygen delivery and indicate the degree of hypoperfusion. Decreasing

lactate levels indicate that tissue perfusion and oxygenation are improving.A patient in septic shock has been prescribed a vasopressor medication. Which assessment finding would the nurse evaluate as indicating the need to question this order?

• The patient's heart rate is 50 bpm.
• The patient's urine output for the last hour was 10 mL.
• The patient's breath sounds include crackles.
• The patient's mentation has not improved.

Answer: 2

Rationales:

• The low heart rate may relate to the shock state. It is not a reason to question the order.
• Vasopressor medications are not effective if there is inadequate circulating blood volume. Poor urine output is one measure of insufficient

fluid resuscitation.

• Crackles in the lungs indicate potential fluid overload. The use of vasopressor medications may reduce the amount of IV fluid needed to

support the patient's perfusion.

• The patient's mentation has not improved because the shock state continues. This is not a reason to question the order.

. A patient is received in the emergency department from emergency medical services after sustaining a brain injury in a fall. She is on a backboard and has a cervical collar in place. She is not moving her lower extremities. What would alert the nurse to the possible development of neurogenic shock?

• The patient's blood glucose is 134 mg/dL.
• The patient reports that she feels a tingling sensation in her lower extremities.
• The patient's friend reports that the patient was unconscious for a "few seconds" after the fall.
• The patient's heart rate drops from 82 bpm to 68 bpm.

Correct:4

Rationales

• Elevation of blood glucose could be attributed to several factors and is not specifically associated with the development of neurogenic

shock.

• The change to a tingling sensation could be attributed to many factors. This is not the finding associated with neurogenic shock.
• While a period of unconsciousness is a significant finding, it is not the finding that would alert the nurse to the potential for neurogenic shock.
• Bradycardia is an indicator that shock is developing. This patient's heart rate is dropping, and the nurse should be aware of the potential for

developing shock.

It is suspected that a patient is developing SIRS. Which assessment findings would the nurse interpret as supporting this suspicion? (Select all that apply.)

• PaCO2 38 mm Hg
• Heart rate 108/min
• WBC 10,000/mm3
• Respiratory rate 22/min
• Temperature of 96.4°F (35.8°C)

Answer: 1, 2, 4, 5

Rationales:.

• The PaCO2 of 38mm Hg is WNL

2.Tachycardia of over 90 beats/min is a criterion for the diagnosis of SIRS.

• WBC greater than 12,000/mm3, less than 4,000/mm3, or greater than 10% immature (band) forms is a criterion for the diagnosis of SIRS.
• A respiratory rate over 20/min is a criterion for the diagnosis of SIRS.
• A core temperature higher than 38°C (100.9°F) or lower than 36°C (96.8°F) is a criterion for the diagnosis of SIRS.

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take?

1.irregular pulse 2.Ecchymosis in the flank area 3.deviated trachea 4.unequal pupils

Correct: 3

A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately?

1.Bleeding around the lacerations 2.Withdrawal of the client in response to painful stimuli 3.Bruises and minimal edema of the eyelids 4.drainage of a clear fluid from the clients nose

Correct: 4

Clear drainage from the client's nose indicates that there is a leakage of CSF and should be reported to the physician immediately Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury?

1.skin ti evaluate lacerations and abrasions 2.lungs for bilateral normal breath sounds 3.pain score and level of alertness 4.urine dipstick for the presence of red blood cells

Correct: 4

Urine dipstick for the presence of red blood cells.It is most important for the nurse to monitor for the presence of blood in the urine as well as assessing the abdomen for rigidity. Clients with crushing injuries to the pelvis are at increased risk of internal hemorrhage. Pelvic injuries are the second cause of death from trauma after head injuries.Assessing the skin for external trauma and monitoring pain and alertness will be performed as part of the overall assessment but are not critical nursing actions at this time. Assessing lung sounds is more critical with chest injuries and rib fractures.