Burns part 2
Treatment includes supporting oxygenation, preventing hypovolemic shock, preventing inadequate gas exchange, pain management and emotional support.
what is lactic acidosis.
The nurse manager is concerned about the negative ratings that her unit has received on patient satisfaction surveys. The first step in addressing this issue from the point of view of quality improvement is which of the following?
1. assemble a team
2. establish a benchmark
3. identify a clinical intervention for review
4. establish outcomes
3. identify a clinical intervention for review
Which of the following statements indicates that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.)
1. “I am thinking about joining the health committee at my church.”
2. “I need to read newspapers, watch news broadcasts, and search the Internet for information related to health.”
3. “I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing.”
4. “Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage.”
1,2,3
MAP decreased 10-15mmhg from baseline, increased ADH, tachycardia, decreased pulse pressure
a. what is compensatory shock
Indications for rapid fluid replacement/blood replacement
Give 2 Examples of a sentinel/never event
1. forceps left in an abdominal cavity
2. patient fall with injury
3. administration of morphine overdose
4. death of a client related to postpartum hemorrhage
5. Death of a pt due to medication error
6. Death due to equipment malfunction
A home health nurse notices significant bruising on a 2-year-old client’s head, arms, abdomen, and legs. The client’s mother describes the client’s frequent falls. What is the best nursing action for the home health nurse to take?
1. Document her findings and treat the client.
2. Instruct the mother on the safe handling of a 2-year-old child.
3. Contact a child abuse hotline.
4. Discuss this story with a colleague.
3 Contact a child abuse hotline
What is first system affected by MODS
The respiratory system
An experienced medical-surgical nurse chooses to work in obstetrics. Upon initial transition, the nurse is:
1. novice
2. proficient
3. competent
4. advanced beginner
NOVICE
. Which of the following actions, if performed by a registered nurse, could result in both criminal and administrative law sanctions against the nurse? (Select all that apply.)
1. Reviewing the electronic health record of a family member who is a client in the same hospital on a different unit
2. Refusing to provide health care information to a client’s child
3. Reporting suspected abuse and neglect of children
4. Applying physical restraints without a written order
5. Completing an occurrence report on the unit
1. Reviewing the electronic health record of a family member who is a client in the same hospital on a different unit
4. Applying physical restraints without a written order
common causes included pericarditis most common, Massive PE, Aortic dissection, Cardiac tamponade (accumulation of fluid in pericardial sac), Tension pneumothorax, Congenital heart defects
Obstructive shock
These are components of a primary survey in emergency nursing
What is establishing a patent airway, providing adequate ventilation, and assessing neurologic function?
A new graduate nurse is asked to serve on the hospital’s quality improvement (QI) committee. The nurse understands that the first step in quality improvement is to:
1. collect data to determine whether standards of care are being met
2. implement a plan to correct the problem
3. identify the standard of care
4. determine whether the findings warrant correction
3. identify the standard of care
Reliability in research refers to:
1. the researcher is trustworthy
2. the research results are 100% accurate
3. the tool used for data collection measured accurately and consistently
4. researchers are available to assist those attempting to repeat the study
3. the tool used for data collection measured accurately and consistently
A nurse cares for a patient with a burn injury who presents with drooling and difficulty swallowing. What action would the nurse take first?
a. Assess the level of consciousness and pupillary reactions.
b. Ascertain the time food or liquid was last consumed.
c. Auscultate breath sounds over the trachea and bronchi.
d. Measure abdominal girth and auscultate bowel sounds.
ANS: C
Inhalation injuries are present in 7% of patients admitted to burn centers. Drooling and difficulty swallowing can mean that the patient is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.
Although patient may be normovolemic, but with acute vasodilation, becomes hypovolemic (relative) & hypotensive
Endotoxin realease, global perfusion deficits, regional perfusion deficits.
a. what is SIRS manifestations
A client is in skeletal traction and has a plaster cast due to a fractured femur. The client experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the client’s toes have become pale and cold but forgets to document this because one of the nurse’s other clients experienced cardiac arrest at the same time. Two days later the client in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.)
1. Failure to document a change in assessment data
2. Failure to provide discharge instructions
3. Failure to provide client education about cast care.
4. Failure to use proper medical equipment ordered for client monitoring
5. Failure to notify a healthcare provider about a change in the client’s condition
1 Failure to document a change in assessment data
5 Failure to notify a healthcare provider about a change in the client’s condition
. Evidence-based nurses ask whether there is a scientific basis for the care they deliver to: