NUR 265 Exam 3 Study Questions

► What is the normal arterial blood gas (ABG) range for the partial
pressure of oxygen (PO2)?
o 80-100 mmHg
o What if it’s higher than 100? What if it’s lower than 80?
 Higher = too much oxygenation … lower = hypoxia
► What is the normal arterial blood gas (ABG) range for the partial
pressure of carbon dioxide (PaCO2)?
o 35-45 mmHg
o What if it’s lower than 35? What is it’s higher than 45?
 Decreased = Respiratory alkalosis … increased =
Respiratory Acidosis
► What is the normal range for the compensatory arterial blood gas
(ABG) bicarbonate (HCO3)?
o 21-28 mEq/L
o What is it’s higher than 28? What if it’s lower than 21?
 Higher = respiratory acidosis (compensation for metabolic
alkalosis) … Lower = respiratory alkalosis (compensating
for metabolic acidosis)
► What is the normal range for glucose?
o 60-100 mg/dL
► What is the range of pre-diabetes for an impaired fasting glucose (IFG)
test?
o 100-125 mg/dL
► What is the range of pre-diabetes for a 2 hour oral glucose tolerance
(IGT) test?
o 140-199 mg/dL
► What is the normal range for a glycosylated hemoglobin (HbA1C) test?
 4-6%
► What is the reference range for the electrolyte phosphorus?
o 3 – 4.5 mg/deciLiter
► What is the reference range for the electrolyte magnesium?
o 1.3 – 2.1 milli-Equivalents/Liter
► What is the reference range for the electrolyte chloride?
o 98 – 106 milli-Equivalents/Liter
► What is the reference range for the electrolyte calcium?
o 9 – 10.5 mg/deciLiter
► What is the reference range for the electrolyte potassium?
o 3.5 – 5 milli-Equivalents/Liter
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► What is the reference range for the electrolyte sodium?

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o 136 – 145 milli-Equivalents/Liter

► What is the reference range for hemoglobin?
o 14-18 gram/deciliter
► What is the reference range for hematocrit?
o 42-52%
► What is the reference range for blood osmolarity?
o 285-295 mOsm/kg
► What are the normal levels for serum creatinine?
o 0.6-1.2
► What are the normal levels for BUN?
o 10-20
► What is the leading cause of death in head trauma patients who arrive
to the hospital?
o Increased Intracranial Pressure
► What causes increased intracranial pressure to kill someone?
o Pressure causes the medulla oblongata to herniate
o What symptoms occur when the medulla oblongata gets
compressed from intracranial pressure?
 Severe bradycardia, widening pulse pressure, elevated
systolic pressure
 What is this presentation of symptoms known as?
 Cushing’s triad
► What section of the brain will experience inflammation from
intracranial pressure first?
o The frontal lobe
o What is the frontal lobe responsible for?
 (1) Level of consciousness (2) judgment (3) awareness
o What symptoms could be expected from injury to the frontal lobe
due to intracranial pressure?
 (1) Change in level of consciousness (the first sign!!!) (2)
lethargy (3) stupor (4) disorientation or alert but not
oriented (5) coma
► What are the earliest signs of increased intracranial pressure?
o Change in level of consciousness = (1) confusion (2) lethargy (3)
slurred speech (4) irritability
► If intracranial pressure is affecting the hypothalamus, how would it be
exhibited?
o Temperature would increase
► What can be done to prevent and detect intracranial pressure?
o Getting baseline vitals
► If a patient exhibits sluggish pupil dilation bilaterally, what cranial
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nerve is being affected?

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o Cranial nerve 3 (oculomotor)

 o What does this mean is happening to the patient?
 Intracranial pressure is reaching the brainstem
► An ovoid pupil reaction has what presentation?
o A size between normal and dilated
o What does this mean about intracranial pressure?
 That it has progressed to the brainstem, specifically the
pons
► Name the 12 cranial nerves in order.
o (1) olfactory (2) optic (3) oculomotor (4) trochlear (5) trigeminal
(6) abducens (7) facial (8) vestibulocochlear (9)
glossopharyngeal (10) vagus (11) accessory (12) hypoglossal
► How do you test cranial nerves 3, 4, and 6?
o Following a pen with eyes through different fields of vision
o What if the patient’s eyes start moving rapidly?
 There is compression of the brainstem
► What are the late signs of ICP?
o (1) severe headaches (2) nausea (3) projectile vomiting (4)
seizures (5) papilledema (6) decerebrate posturing (7)
decorticate posturing (8)ataxia (9) nuchal rigidity or stiff neck
(10) cerebrospinal fluid leaking from ears or otorrhea (11)
cerebrospinal fluid leaking from nose or rhinorrhea
o How do you assess for papilledema and what does it mean is
happening?
 With an ophthalmoscope and increased blood flow to optic
disc in the eye
o How can you tell the fluid leaking from the patient’s nose is
cerebrospinal fluid?
 From the halo sign created by the glucose and protein in
the droplet
o Why don’t you want to move the patient with a stiff neck?
 Because it could cause phrenic nerve damage
► What is decorticate posturing?
o Abnormal posturing from lesions in the corticospinal pathways
o What does this do to the body? [HINT:: think cocoon]
 Arms, wrists, and fingers are flexed with internal rotation in
the legs
► What is decerebrate posturing? [HINT:: think butterfly]
o Abnormal posturing from dysfunction in the brainstem
o How is it characterized?
 Extension of arms and legs, pronation of the arms, body
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spasms that
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► What should you assume for any patient with a head injury?
 o That they also have spinal cord injury too
► True or False: It is okay to have the head of the bed down when an ICP
patient is sleeping.
o False – never have the bed flat
o How should they lay?
 45 degrees, with their head midline and neutral
► What is the drug of choice for a patient with ICP and why?
o Mannitol because it works quickly to reduce the fluid buildup in
the brain
o How would you know that the medication was working?
 The patient would have an increase in urinary output
o What is an adverse reaction?
 Dehydration or hypovolemia
o What should you do before administering the Mannitol? Why?
 Filter it because it can crystallized
► Besides Mannitol, what other medications could be used for a patient
with ICP? Why for each?
o (1) Lasix – to help lower the sodium and water flow out of the
circulatory system (2) Dilantin – because they are automatically
at risk for seizures (3) glucocorticoids – to reduce the swelling (4)
aspirin or Tylenol – to reduce fever (unless they are bleeding) (5)
opioids/morphine/fentanyl – to prevent severe pain that could
worsen the ICP
o Why should a nurse be cautious if her ICP patient is taking
opioids or fentanyl?
 Because side effects can mimic a change in level of
consciousness
► Under what conditions would a barbiturate coma be considered for a
patient with ICP?
o To control intracranial hypertension that cannot be control by any
other means
o How does the barbiturate coma work? [name 3]
 (1) By decreasing the metabolic demands of the brain (1)
decreasing cerebral blood flow (3) stabilize cell membranes
(4) decrease formation of vasogenic edema (5) produce a
more uniform blood supply
o How does the patient present?
 Completely unresponsive
► What could an injured or compressed pituitary gland cause in a patient
with a traumatic brain injury?
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o Diabetes insipidus (DI) or Syndrome of Inappropriate ADH

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(SIADH)
► You are given shift report and find out you have a new patient with a
traumatic brain injury, how should you expect to manage their
nutrition status?
o Parenterally
► A doctor has decided to insert a device to better monitor the ICP
pressure inside of the patients skull. How is this device inserted into
the skull of the patient?
o Through a burr hole (or key-hole craniotomy)
► What may a doctor elect to do when a patient’s ICP cannot be
controlled, and what is the benefit?
o A craniotomy; to remove ischemic (tissue starved of oxygen) or
the temporal lobes to allow room for the brain to expand without
worsening the ICP
► What is the difference between an open-head injury and closed-head
injury?
o Open head is where the something penetrates the skull, closed-
head is where the skull is still intact
► What are the 3 areas of the Glasgow Coma Scale?
o (1) eye opening (2) verbal (3) motor
► What kind of score is good, and what kind is bad, on the Glasgow Coma
Scale?
o Low score is bad, and high score is good
► Where does a basilar skull fracture occur?
o At the base of the skull, where it connects to the neck
► What kind of skull fracture is at the highest risk of hemorrhage? Why?
o Basilar skull fracture; because it is close to the carotid artery
o What other problems can come along with a basilar skull
fracture? [name 3]
 (1) cerebrospinal fluid leaking from nose or ears (2)
damage to cranial nerve 1 (olfactory), 2 (optic), 7 (facial), 8
(vestibulocochlear) (3) infection
► Concussion or Contusion: Which has no structure damage to the brain?
o Concussion
► Concussion or Contusion: Which has structure damage to the brain?
o Contusion
► Is an epidural hematoma, subdural hematoma, or intracerebral
hemorrhage an arterial bleed?
o Epidural hematoma
► Is an epidural hematoma, subdural hematoma, or intracerebral
hemorrhage a venous bleed?
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o Subdural hematoma
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► Is an epidural hematoma, subdural hematoma, or intracerebral
hemorrhage a bleed into the brain tissue?
o Intracerebral hemorrhage
o What most likely causes it?
 Aneurysm/AV malformation rupturing from trauma or
increased blood pressure
► Does an epidural hematoma, subdural hematoma, or intracerebral
hemorrhage have poor prognosis?
o Intracranial hemorrhage because it causes increased intracranial
pressure very quickly
► Does an epidural hematoma, subdural hematoma, or intracerebral
hemorrhage have high mortality rate? Why?
o Subdural hematoma because it is usually unrecognized
► Does an epidural hematoma, subdural hematoma, or intracerebral
hemorrhage most likely present with personality change?
o Subdural hematoma
► Does an epidural hematoma, subdural hematoma, or intracerebral
hemorrhage most likely present with lucid intervals and momentary
inconsciousness?
o Epidural hematoma
► What is autonomic dysreflexia? What is it characterized by? [name 5]
o Uncontrolled sympathetic output ; (1) severe hyPERtension (2)
bradycardia (3) severe headache (4) flushing of face or chest (5)
pale extremities (6) nasal congestion (7) sweating (8) nausea (9)
goose bumps (10) blurred vision
► What is the number 1 priority nursing intervention that can be
implemented for someone with autonomic dysreflexia?
o Sitting up the head of the bed/High Fowler’s position
o What can be done next? [name 3]
 (1) notify the doctor to treat high blood pressure (2) check
catheter and/or bladder (3) loosen tight clothing (4)
administer antihypertensives
► Which patient is at a higher risk of developing autonomic dysreflexia,
and why? : the patient with C4-C5 injury, T7-T8 injury, or S1-S2 injury

o C4-C5 because it affects patients with a T6 injury or higher

► What complication can occur if autonomic dysreflexia isn’t treated in
time?
o Stroke (from high BP)
► A patient is found to have a concussion, a family member calls to say
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the patient is experiencing headaches. Should you tell them this is

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normal or to go to the nearest ER?

 o Normal (Tylenol can help)
► A patient is found to have a concussion, a family member calls to say
the patient is experiencing blurred vision. Should you tell them this is
normal or to go to the nearest ER?
o Go to the ER
► A patient is found to have a concussion, a family member calls to say
the patient is experiencing dizziness. Should you tell them this is
normal or to go to the nearest ER?
o Normal (only for 24 hours)
► A patient is found to have a concussion, a family member calls to say
the patient is experiencing worsening headache. Should you tell them
this is normal or to go to the nearest ER?
o Go to the ER
► A patient is found to have a concussion, a family member calls to say
the patient is experiencing clear fluid from ear. Should you tell them
this is normal or to go to the nearest ER?
o Go the ER!
► A patient is found to have a concussion, a family member calls to say
the patient is experiencing increasing sleepiness. Should you tell them
this is normal or to go to the nearest ER?
o Go to the ER
► How could a patient with a head injury develop bacterial meningitis?
o Bacteria moving backward through rhinorrhea or otorrhea
► How should a patient who has undergone supratentorial surgery be
positioned?
o (same as ICP patient) head of bed 30 degrees, avoid hip flexion,
with head midline and neutral
► How should a patient who has undergone infratentorial (brainstem)
craniotomy be positioned? Why?
o Flat or either side for 24-48 hours to prevent pressure on neck
incision site
► What is shock?
o When there isn’t enough oxygenation and tissue perfusion (blood
flow) to meet the needs of the vital organs
► What are the 4 different types of shock?
o (1) cardiogenic (2) distributive (3) obstructive (4) hypovolemic
o What 3 subtypes does distributive shock include?
 (1) septic (2) anaphylactic (3) neurogenic/spinal
► How does distributive shock occur?
o When the blood volume is distributed to interstitial tissues,
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where it can’t circulate and deliver oxygen

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► What occurrence causes neural-induced distributive shock? [THINK::
spinal cord injury resulting in…]
o Loss of sympathetic tone/innervation
► Tissue and organ perfusion is related to mean arterial pressure. What 3
factors influence mean arterial pressure?
o (1) total blood volume (2) cardiac output (3) size of vascular bed
o Which factor is most related to distributive shock?
 Size of vascular bed
o Which factor is most related to a massive hemorrhage?
 Total blood volume
o Which factor is most related to the patient experiencing
advanced heart failure?
 Cardiac output
► Why are the earliest neuromuscular manifestations of shock anxiety
and restlessness?
o Because the brain is most vulnerable to water and glucose
deprivation
► Which type of shock would be different, manifesting hypotension and
bradycardia?
o Neurogenic/spinal shock
► Why does the progression of pale to mottled indicate a worsening
event in a patient with shock?
o Mottled is a sign of impending death
► In shock, why are renal manifestations decreased urinary output and
increased specific gravity?
o Not enough blood, so no pee can be made (no blood, no pee-
pee)
► In which of the 4 stages of shock could you expect the mean arterial
pressure to decrease by less than 10 millimeters of mercury?
o Early or initial stage
► What may be the only objective manifestation of the early or initital
phase of shock? [know both]
o A heart and respiratory rate increased from the patient’s baseline
level, or a slight increase in diastolic blood pressure
► In which of the 4 stages of shock could you expect the mean arterial
pressure to decrease by 10-15 millimeters of mercury from the
baseline?
o Non-progressive or compensatory stage
o What else could you expect to happen during this stage?
 Renal/kidney and hormonal compensatory mechanisms are
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activated (or kidneys and hormones try to compensate)

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 What will this do?

  (1) decreased urinary output (2) increase sodium
reabsorption (3) widespread blood vessel constriction
(4) tissue hypoxia of non-vital organs/skin and GI
tract
 How does this affect acid-base and electrolyte balances?
 Leads to metabolic acidosis and hyperkalemia
► Which of the 4 stages of shock would you expect the mean arterial
pressure to have dropped more than 20 millimeters of mercury below
the baseline?
o Progressive or intermediate stage
o What happens in this stage?
 Compensation mechanisms fail so tissues begin to die from
lack of oxygen
o What would lab data look like in this stage? [know all]
 (1) low pH (2) rising lactic acid (3) worsening metabolic
acidosis (4) hyperkalemia
► Which of the 4 stages of shock would you expect the patient to stop
responding to life-saving interventions?
o Refractory or irreversible stage
o What are the manifestations of this stage?
 (1) rapid loss of consciousness (2) non-palpable pulses (3)
cold, dusky extremities (4) shallow respirations (5)
unmeasurable oxygen saturations
o What is misleading about this stage?>
 That the patient may start to look better for a brief period
► True or False: Only an RN, rather than an LPN or CNA, should assess the
vital signs of a patient at risk for hypovolemia.
o TRUE
► True or False: Because changes in systolic blood pressure are not
always present in the initial stages of shock, use an EKG as the main
indicator of shock presence or progression.
o FALSE; use changes in pulse rate and quality as the main
indicators
► What is MODS? Describe how causes damage.
o Multiple Organ Dysfunction Syndrome; dying cells release toxins
that begin a ripple effect
o What does this cycle of toxins trigger? Why is it bad?
 Microthrombi or small clots; because they block tissue from
getting oxygen, causing further damage to the cells
► Which organs are the first to go when the body is affected by MODS?
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o (1) liver (2) heart (3) brain (4) kidneys

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o Which is the most profound?

  Damage to the heart
► Consider a patient with hypovolemic shock. What position should they
be in?
o Feet elevated, head flat (or less than 30 degrees) … aka Modified
Trendelenburg
 In which type of shock would this be an exeception and
why?
 Cardiogenic, because it would cause the heart to fail
faster
► What is the #1 priority for a hypovolemic patient?
o Airway!
► True or False: Only normal salin should be used to infuse blood.
o TRUE
o What would happen if you used Lactated Ringer’s instead?
 Causes clots in the blood that is infusing
o What size gauge should be used for this patient?
 18 Gauge
► Why is anaphylactic shock considered a type of distributive shock?
o Because massive vasodilation from massive amounts of
histamines
o What does this cause?
 Bronchospasms
► What is the drug of choice for an anaphylactic shock?
o Epinephrine
► What causes damage in sepsis?
o Endotoxins released from bacteria in the blood
► What is SIRS?
o An inflammatory response that triggers a cascade of problems in
septic shock
► Hypodynamic or Hyperdynamic state of shock: Widespread
vasodilation and blood pooling?
o Hypodynamic
► Hypodynamic or Hyperdynamic state of shock: pooled blood stimulates
increased cardiac output, tachycardia, increased systolic blood
pressure, little to no cyanosis, warm extremities, rapid respiratory rate,
and increased oxygen saturation?
o Hyperdynamic
o True or False: this patient is in recovery
 False; this is a false recovery, they are actually getting
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worse
► Hypodynamic or Hyperdynamic state of shock: decreased cardiac
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output?
 o Hypodynamic
► Hypodynamic or Hyperdynamic state of shock: temperature varies,
afebrile or a slowly increasing trend?
o Hypodynamic
► Hypodynamic or Hyperdynamic state of shock: state that is often
missed because of a short duration?
o Hypodynamic
► Hypodynamic or Hyperdynamic state of shock: microthrombi begin to
form, leading to ischemia in some organs?
o Hypodynamic
► Hypodynamic or Hyperdynamic state of shock: state with DIC?
o Hyperdynamic
o What does DIC stand for? And what is it?
 Disseminated intravascular coagulation; it is when platelets
and clotting factor get used up leading to uncontrolled
bleeding
 What would be the first possible sign for a patient with
DIC?
 Bleeding IV site
 What can be done to intervene with the uncontrolled
bleeding?
 Giving the patient fresh frozen plasma or clotting
factor
► Massive hemorrhage and septic shock are 2 common causes for what
conidition?
o DIC
► What is the hallmark of sepsis?
o Increasing serum lactate level; normal or low white blood cell
count; decreasing segmented neutrophil level with a rising band
neutrophil level (left shift)
► What percentage of the body has been burned if the burn covers both
of the lower extremities?
o 36%
► Which kind of burn would result from a sunburn?
o Superficial
► Which kind of burn could result from being electrocuted?
o Full thickness or deep full thickness
► Which kind of burn could result from hot grease?
o Deep partial thickness, full thickness, or deep full thickness
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► What kind of burn is only as deep as the epidermis?

o Superficial
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► What kind of burn is as deep as the entire epidermis and dermis?

 o Superficial partial-thickness
► What kind of burn is as deep as the subcutaneous fat?
o Full-thickness burn
► What kind of burn can go as deep as to char the bone?
o Deep full-thickness
► Which kinds of burns would the color be pink or red?
o Superficial and superficial partial-thickness
► Which kind of burn would the color be red to white?
o Deep partial thickness
► Which kind of burn would the color be black?
o Deep full thickness
► Which kind of burn would the color be black and brown?
o Full thickness
► What is the term for hard, dry, leathery dead skin?
o eschar
► Which kind of burn don’t have eschars [“es-cars”]?
o Superficial and superficial partial-thickness
► True or False: a superficial partial-thickness burn requires a graft, but a
superficial does not.
o False; neither requires a graft
o Which types of burns require grafts?
 (1) full thickness (2) deep full thickness
► True or False: The only visible difference between a superficial and
superficial partial-thickness burn is that the superficial partial-thickness
burn may have blisters.
o True
► Which types of burns are associated with pain?
o (1) Superficial (2) superficial partial-thickness (3) deep partial-
thickness
► Which type of burns produce hard, inelastic eschars [“es-cars”]?
o (1)full-thickness (2) deep full-thickness
► Which type of burns are associated with no pain?
o (1) full thickness (2) deep full thickness
o Why isn’ there any pain?
 Because the nerve endings have burned away
► What is the drug of choice for a patient who is badly burned?
o Morphine
► What kind of assessment can be done on a burn patient to avoid acute
compartment syndrome?
o A neurovascular check
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► What is done to an eschar to relieve pressure on a body part and

continue blood flow?
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o Escharotomy (cutting the eschar)

► If death occurs during the first 48 hours after a burn, what is the cause
most likely from?
o Hypovolemia
o How does heat cause hypovolemia?
 Heat makes the capillaries more permeable, so fluid shifts
from intravascular spaces to interstitial/3rd space
 What effect does this have on H&H and blood
concentration?
 (1) increased hematocrit (2) increased hemoglobin
(3) increased concentration/osmolarity
► What phase occurs, starting 36 hours after a burn, when capillaries
start to heal and stop leaking?
o The diuretic phase
o What is the fluid shift that occurs?
 From interstitial back into intravascular
o What effect does this have on acid/base and electrolytes? Why
for each?
 (1) metabolic acidosis – because loss of bicarbonate in
urine (2) hypokalemia – because potassium moves back
into the cell (3) Hyponatremia – because it’s excreted in
the urine
► If death occurs after the first 48 hours after a burn, what is the cause
most likely from?
o Sepsis
► What is Curling’s ulcer?
o A stress ulcer that develops as fast as 24 hours after the
stressors
o What causes this?
 Cortisol that erodes mucus membrane
► True or False: Burn victims are in a hypo-metabolic state.
o False! They are in a hyper-metabolic state
► What kind of injury is called the “Grand Masquerader”, and why does it
have that name?
o Electrical injuries/Burns, because the entrance wounds can be
very small, but the injuries between the entrance and exit
wounds are great
► True or False: The short the contact with the source of electricity, the
greater the damage.
o FALSE! The longer the contact the greater the damage
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o Then why doesn’t a person who is being electrocuted by a

downed power cord just let go?
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  Because electricity causes muscle contraction thus leading
to increased contact time
► Why would a nurse find a EKG helpful when caring for a burn victim?
o To watch for dysrhythmias that could lead to V-Fib
► You have a patient coming from the ER and it was reported that they
were rescued from a house fire. What signs should you watch for that
may indicate airway obstruction or inhalation injury? (Name 5.)
o (1) fire occurred in a closed space (2) burns occurred to the face
(3) visible charcoal in teeth or gums (4) people who were
unconscious during fire (5) people whose eyebrows, hair,
eyelashes, nasal hairs are singed (6) coughing up carbonaceous
sputum/soot (7) hoarse voice (8) brassy cough (9) stridor (10)
poor oxygenation/ventilation (11) ulceration or edema of airway
mucosa (12) wheezing (13) bronchospasm
► What is a colorless, odorless gas and is leading cause of death in a
fire?
o Carbon monoxide
o What make carbon monoxide dangerous?
 It has a greater attraction to hemoglobin than oxygen
 What will a victim of carbon monoxide look like that differs
from other patients that were also starved of oxygen?
Why?
 They will appear cherry red because carbon
monoxide is a powerful vasodilator
o What is the nursing intervention for a patient that suffers carbon
monoxide poisoning?
 100% oxygen
► What fluid is used for a burn patient when aggressive fluid
resuscitation measures are put in place?
o Lactated Ringer’s/Modified Parkland
o How is this administered?
 Half of the prescribed volume is given in the 1st 8 hours,
and then the remaining dose is spread out over the next 16
hours
o What is the best indicator that this therapy is working?
 30 mL or more of urine output per hour
► What is the name of the burn phase that begins at the time of the
burn?
o The emergent phase
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o What are the goals of this phase?

 (1) Preventing hypovolemic shock (2) preserving vital
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organs
► What is the name of the burn phase that begins with the initiation of
fluids?
o Resuscitative phase
o What are the goals of this phase?
 (1) to prevent shock by maintaining adequate blood
volume (2) maintaining organ perfusion/blood flow to
organs
► What is the name of the burn phase that begins once the patient is
hemo-dynamically stable, capillaries are no longer permeable, and
diuresis has begun?
o The acute phase
o What are the goals of this phase?
 (1) Restorative therapy (2) closing the wound (3) wound
care (4) nutritional support (5) pain management (6)
physical therapy
► What is the name of the burn phase that extends beyond
hospitalization?
o Rehabilitative phase
o What is the goal of this phase?
 gaining independence and function
► By which route are most of the medications, like antibiotics, given to
burn victims?
o Topical
► What is the most common cause of sepsis for a burn victim?
o Their own GI tract (diarrhea from TPN)
► True or False: When caring for a patient with severe burns you should
use a sterile technique, washing your hands before and after care.
o True
► What muscular problem are burn victims most at risk for?
o Contractures
► True or False: Burn patients have a recovery and return to their normal
lives.
o False! Patients will never be the same again and the injuries take
a great toll on them, even after healing.
NCLEX EXAMINATION CHALLENGE

► An 88-year old woman is admitted for cardiac rehabilitation after an

insertion of 2 coronary artery stents. While ambulating with her walker,
the patient reports chest pain. What do you do?
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o Stop her activity and provide a rest period

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► True or False: When teaching your newly paraplegic patient about his
bowel retraining, include ways to include exercises that involves weight
lifting and propelling his wheelchair.
o False
► You are assessing the wound of a patient burned as a result of stepping
into a bathtub filled with very hot water. Which assessment finding of
the burned areas on the tops of both feet do you use as a basis to
document a probable full-thickness injury?
o Thrombosed blood vessels are visible beneath the skin surface
► A patient who tripped while carrying an open kettle of hot water
received scald burns to the entire chest, the entire anterior section of
the right arm, the right half of the abdomen, and the anterior portion of
the right leg from the groin to the knee. At what percentage of the total
body surface area does the nurse calculate the injury using the rule of
nines?
o 22-23%
► Which assessment does the nurse perform first on the client just
admitted after an electrical injury with contact sites on the left hand
and the left foot?
o EKG
► A patient with 45% burns has a hematocrit of 52% 10 hours after the
burn injury and 6 hours after fluid resuscitation was started. What is
the nurse’s best action?
o Assess the patient’s blood pressure and urine output
► The patient with burns to the head, neck, and upper body from a house
fire starts drooling uncontrollably about 8 hours after the injury. What is
the nurse’s best first action?
o Notify rapid response
► A burned patient client newly arrived from an accident scene is
prescribed 4 mg of morphine sulfate IV. What is the most important
reason the nurse administers the analgesic to the patient by the IV
route?
o The danger of an overdose during fluid remobilization is reduced
► A patient asks the nurse not to remove the loosened bits of skin and
tissue during the dressing change, saying “the more skin you take off
the longer it will take me to heal”. What is the nurse’s best response?
o The tissue isn’t living and as long as it’s there, real healing can’t
start
► True or False: A patient that experienced burns to the head and neck
plans to cut their grass on the mornings when the sun is not as strong
16

is a good indicator of positive adjustment to the injury.

o True
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► Why are the manifestations of most types of shock the same
regardless of what specific events or condition cause the shock to
occur?
o The sympathetic nervous system is triggered by any type of
shock and initiates the stress response
► A patient has just had a lumbar laminectomy. When should you teach
them to call the surgeon immediately?
o If clear drainage is leaking from the surgical site
► A patient is admitted to the critical care unit with possible Guillain-
Barre syndrome. What assessment is the most important for this
patient?
o Respiratory assessment
► When caring for a client with myasthenia gravis, what nursing activities
may be safely delegated to a nursing assistant?
o (1) feeding dinner to the client (2) assisting with ambulation (3)
assisting with communication (4) recording fluid and food intake
► During a client neurologic assessment, the nurse finds that he is
arousable only if his trapezius muscle is pinch. How will the nurse
document is level of consciousness?
o Stuporous
► An alert and oriented patient is admitted to the ER with a moderate
head injury. What assessment finding will you report immediately to
the doctor? Fatigue, slight dizziness, headache, or sudden drowsiness
o Sudden drowsiness
► A patient returns from the PACU after a craniotomy for removal of a
right frontal lobe tumor. How will the nurse position the patient?
o Elevate the patient’s head at least 30 degrees to promote
venous drainage
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