CORRECT AND WELL DETAILED
The nurse cares for an adolescent patient who is dying. The patients parents are interested in
organ donation and ask the nurse how the decision about brain death is made. Which response
by the nurse is most
appropriate? - ANSWER Brain death has occurred if there is no breathing and certain
reflexes are absent.
When should you suction endotracheal tube patient? - ANSWER Auscultated
adventitious breath sounds
Which action should the nurse take first when a patient complains of acute chest pain and
dyspnea soon after insertion of a centrally inserted IV catheter? - ANSWER Auscultate
the patients breath sounds.
Patient with potassium level of 2.7 - ANSWER Shallow Breath (HR 55 irregular??)
A 25-year-old male patient has been admitted with a severe crushing injury after an industrial
accident.. Which laboratory result will be most important to report to the health care provider?
- ANSWER Serum potassium level 6.5 mEq/L (may cause cardiac arrest)
Symptom of potassium level of 5.9? - ANSWER Diarrhea
A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL.
Which assessment would be most important for the nurse to make? - ANSWER Daily
alcohol intake
Hypocalcemia manifestations - ANSWER tetany and ECG changes
1
,Cause of Metabolic acidosis - ANSWER Excess diarrhea
respiratory alkalosis manifestations - ANSWER hyperventilation and anxiety
Intervention for patient with tachypnea. 38 breaths per minute - ANSWER non-
rebreather without O2 (similar to paper bag effect for hyperventilation).
Tracheostomy tube suctioning action? - ANSWER Limit suctioning to no longer than 10
seconds
Tracheal suctioning of patient with increasing SOB prior to procedure, how can suctioning
outcomes be evaluated? - ANSWER Check O2 saturation.
Potential cause of prerenal acute kidney injury? - ANSWER Dehydration
Heath problem predisposing to CKD? - ANSWER Diabetic nephropathy
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To
maintain adequate nutrition, the nurse should plan to take which action? -
ANSWER Insert a feeding tube and initiate enteral feedings.
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn
unit. Using
the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated
Ringers solution
that the nurse will administer during the first 8 hours?
(exact question not on exam but know how to calculate) - ANSWER 600 mL
The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the
first 24 hours.
2
,Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours:
4 80 30 =
9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
The nurse estimates the extent of a burn using the rule of nines for a patient who has been
admitted with
deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of
the patients total body surface area (TBSA) has been injured? - ANSWER 27%
When using the rule of nines, the anterior trunk is considered to cover 18% of the patients body
and each arm
is 9%.
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland
formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The
initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse
infuse the IV fluids? - ANSWER 938 mL/hour
Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and
the other half
over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938
mL/hr.
- not exact question, know how to calculate this formula
A patient arrives in the emergency department with facial and chest burns caused by a house
fire. Which action should the nurse take first? - ANSWER Auscultate the patients lung
sounds.
A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway
and breathing is
the priority. The other actions will be completed after airway management is assured.
3
, A child is admitted with extensive burns. The nurse notes burns on the child's lips and singed
nasal hairs. The nurse should suspect what condition? - ANSWER Inhalation injury
Assessing a crying patient with 2nd and 3rd degree burns on hands/arms, priority action? -
ANSWER Assess BP and HR
1. Kidney stone term for stone obstructing ureter? - ANSWER Renal colic
Risk factors for kidney stones include - ANSWER Immobility
Dehydration
Hypercalcemia
Obesity
(Research causes/risk factors)
Patient education for patient with UTI and history of kidney stones prescribed sulfa antibiotic. -
ANSWER Increase fluids to 2 to 3 liters.
UTI assessment finding in older adult requiring attention immediately? -
ANSWER Confusion
Postrenal cause of kidney injury? - ANSWER BPH
Older adult with pneumonia signs and symptoms? - ANSWER Lethargy and Confusion
Priority intervention for patient with pneumonia and a temperature of 101.4 F? -
ANSWER Administer Levofloxacin (to decrease infection which will also lower fever),
4
The nurse cares for an adolescent patient who is dying. The patients parents are interested in
organ donation and ask the nurse how the decision about brain death is made. Which response
by the nurse is most
appropriate? - ANSWER Brain death has occurred if there is no breathing and certain
reflexes are absent.
When should you suction endotracheal tube patient? - ANSWER Auscultated
adventitious breath sounds
Which action should the nurse take first when a patient complains of acute chest pain and
dyspnea soon after insertion of a centrally inserted IV catheter? - ANSWER Auscultate
the patients breath sounds.
Patient with potassium level of 2.7 - ANSWER Shallow Breath (HR 55 irregular??)
A 25-year-old male patient has been admitted with a severe crushing injury after an industrial
accident.. Which laboratory result will be most important to report to the health care provider?
- ANSWER Serum potassium level 6.5 mEq/L (may cause cardiac arrest)
Symptom of potassium level of 5.9? - ANSWER Diarrhea
A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL.
Which assessment would be most important for the nurse to make? - ANSWER Daily
alcohol intake
Hypocalcemia manifestations - ANSWER tetany and ECG changes
1
,Cause of Metabolic acidosis - ANSWER Excess diarrhea
respiratory alkalosis manifestations - ANSWER hyperventilation and anxiety
Intervention for patient with tachypnea. 38 breaths per minute - ANSWER non-
rebreather without O2 (similar to paper bag effect for hyperventilation).
Tracheostomy tube suctioning action? - ANSWER Limit suctioning to no longer than 10
seconds
Tracheal suctioning of patient with increasing SOB prior to procedure, how can suctioning
outcomes be evaluated? - ANSWER Check O2 saturation.
Potential cause of prerenal acute kidney injury? - ANSWER Dehydration
Heath problem predisposing to CKD? - ANSWER Diabetic nephropathy
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To
maintain adequate nutrition, the nurse should plan to take which action? -
ANSWER Insert a feeding tube and initiate enteral feedings.
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn
unit. Using
the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated
Ringers solution
that the nurse will administer during the first 8 hours?
(exact question not on exam but know how to calculate) - ANSWER 600 mL
The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the
first 24 hours.
2
,Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours:
4 80 30 =
9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
The nurse estimates the extent of a burn using the rule of nines for a patient who has been
admitted with
deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of
the patients total body surface area (TBSA) has been injured? - ANSWER 27%
When using the rule of nines, the anterior trunk is considered to cover 18% of the patients body
and each arm
is 9%.
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland
formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The
initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse
infuse the IV fluids? - ANSWER 938 mL/hour
Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and
the other half
over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938
mL/hr.
- not exact question, know how to calculate this formula
A patient arrives in the emergency department with facial and chest burns caused by a house
fire. Which action should the nurse take first? - ANSWER Auscultate the patients lung
sounds.
A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway
and breathing is
the priority. The other actions will be completed after airway management is assured.
3
, A child is admitted with extensive burns. The nurse notes burns on the child's lips and singed
nasal hairs. The nurse should suspect what condition? - ANSWER Inhalation injury
Assessing a crying patient with 2nd and 3rd degree burns on hands/arms, priority action? -
ANSWER Assess BP and HR
1. Kidney stone term for stone obstructing ureter? - ANSWER Renal colic
Risk factors for kidney stones include - ANSWER Immobility
Dehydration
Hypercalcemia
Obesity
(Research causes/risk factors)
Patient education for patient with UTI and history of kidney stones prescribed sulfa antibiotic. -
ANSWER Increase fluids to 2 to 3 liters.
UTI assessment finding in older adult requiring attention immediately? -
ANSWER Confusion
Postrenal cause of kidney injury? - ANSWER BPH
Older adult with pneumonia signs and symptoms? - ANSWER Lethargy and Confusion
Priority intervention for patient with pneumonia and a temperature of 101.4 F? -
ANSWER Administer Levofloxacin (to decrease infection which will also lower fever),
4
