Ch11 Exam Questions Nursing Care Of Patients Experiencing - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 11 Nursing Care of Patients Experiencing Trauma and Shock
1) A patient is brought to the emergency department with injuries sustained in a motor vehicle crash. What should the nurse consider as the cause of this patient's injuries?
1. Trauma
2. Not wearing a seat restraint
3. A drunk driver
4. Not paying attention while driving
Page Ref: 285
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
2) A patient recovering from a traumatic gunshot wound asks when discharge will occur. Which response should the nurse make?
1. "Right now there is no way of knowing how long you will be hospitalized."
2. "I would say in a few weeks."
3. "Probably never."
4. "As soon as the wound heals, you can return to work."
Page Ref: 286
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Stress Management
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
3) An older patient is admitted after falling on the steps at home. Which component of trauma should the nurse consider when planning care for the patient? Select all that apply.
1. Host
2. Environment
3. Intention
4. Source
5. Transmission
Page Ref: 286
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
4) A patient comes into the emergency department with leg pain after falling on ice. For which classification of injuries should the nurse expect to plan care for this patient?
1. Class 3 minor
2. Class 1 minor
3. Class 1 penetrating
4. Class 3 penetrating
Page Ref: 287
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
5) A patient is brought to the emergency department with injuries sustained when a wall collapsed in the home. Which mechanism of injury most likely caused this patient's injuries?
1. Crushing
2. Shearing
3. Deceleration
4. Blast
Page Ref: 287
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
6) A patient was admitted with a head injury caused by rapid acceleration and deceleration. How should the nurse expect this patient's injuries to be classified?
1. Blunt
2. Shearing
3. Blast
4. Minor
Page Ref: 287
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
7) A patient experiences a thermal injury. Which mechanism should the nurse consider as the most likely cause of this patient's injuries?
1. Fire
2. Lightning
3. Ultraviolet radiation
4. Gunshot
Page Ref: 286
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
8) A pediatric patient is admitted after ingesting a household cleaning solution. For which energy source should care be planned for this patient?
1. Chemical
2. Physical
3. Thermal
4. Mechanical
Page Ref: 286
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
9) A patient recovering from a motor vehicle accident asks how so many injuries occurred when the other car "barely" made contact. How should the nurse respond?
1. "The car that hit you transferred a large amount of energy to your body, causing these injuries."
2. "You have other health problems that make the injuries worse."
3. "The driver of the other car intended to hit you."
4. "Because you are older, your injuries will be worse."
Page Ref: 286
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
10) A construction worker was admitted after falling from the roof of a building. Which energy source should the nurse use to plan this patient's care?
1. Gravitational
2. Mechanical
3. Physical
4. Electrical
Page Ref: 286
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
11) A patient with injuries from a motor vehicle crash develops hypotension and severe jugular distension with a tracheal deviation. What should the nurse suspect is occurring in this patient?
1. Tension pneumothorax
2. Hemorrhage
3. Compensatory shock
4. Hypovolemic shock
Page Ref: 289
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
12) A patient experiences blunt trauma to the abdomen after a motor vehicle crash. What should be assessed first?
1. Airway for patency
2. Abdomen for any abnormalities
3. Cervical spine for tenderness
4. Signs of neurological deficits
Page Ref: 293
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
13) A patient with a penetrating wound to the neck has dyspnea, cyanosis, and evidence of subcutaneous emphysema. What should the nurse expect to be completed first for this patient?
1. Intubate because of the severe wound.
2. Notify the next of kin.
3. Prepare for x-rays of the lumbar area to assess for fractures.
4. Administer a beta blocker to alleviate the sympathetic response.
Page Ref: 288
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
14) The nurse suspects that a patient who was in a motor vehicle crash does not have a cervical spine injury. What did the nurse assess to come to this conclusion?
1. Alert without midline cervical tenderness
2. Lacking motor response in lower extremities
3. Lacking deep tendon reflexes
4. Lethargic and confused
Page Ref: 288
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
15) A patient with physical injuries sustained in a gang fight has a blood pressure of 80/50 mmHg, with a pulse of 120 and thready. Which diagnostic test should the nurse expect to be performed to provide the fastest information?
1. Sonogram
2. Complete blood count
3. Urinalysis
4. Serum electrolyte levels
Page Ref: 295
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
16) A patient is admitted with possible head and spinal cord injuries sustained after falling from a ladder. Which diagnostic test should the nurse expect to be prescribed that will identify the type and extent of this patient's injuries?
1. Magnetic resonance imaging
2. Cervical spine x-rays
3. Spinal cord x-rays
4. Cerebral angiogram
Page Ref: 295
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
17) A victim of a multivehicle automobile crash has slurred speech and is lethargic. Which diagnostic test should be anticipated for this patient? Select all that apply.
1. Blood alcohol level
2. Urine drug screen
3. Skull x-rays
4. Chest x-ray
5. Urinalysis
Page Ref: 295
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
18) A trauma patient is experiencing ongoing progression of shock. What finding caused the nurse to come to this conclusion?
1. Decrease in serum glucose level
2. Drop in blood urea nitrogen level
3. Increased eosinophil level
4. Low serum cardiac enzyme level
Page Ref: 306
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
19) A patient with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. Because there is not enough time for type and crossmatch, which type of blood will the patient likely receive?
1. O
2. A
3. B
4. AB
Page Ref: 295
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
20) A patient with multiple gunshot wounds has received 8 units of blood; however, the blood bank has run out of blood for the patient. For which blood type can the patient receive any type of blood?
1. AB
2. A
3. B
4. O
Page Ref: 295
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
21) A patient admitted with multiple injuries is prescribed an intravenous colloid solution. Which solution would be appropriate for the nurse to infuse?
1. 25% albumin
2. 0.9% normal saline
3. Dextrose 5% and 0.45% normal saline
4. Dextrose 5% and water
Page Ref: 313
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
22) A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. Which solution should the nurse recognize would be best for this patient?
1. Ringer's lactate
2. Dextrose 5% and water
3. Dextrose 5% and 0.45% normal saline
4. Dextrose 5% and 0.9% normal saline
Page Ref: 313
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; 1. Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
23) A patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which finding indicates this medication has been effective?
1. Increased heart rate
2. Reduced heart rate
3. Decreased respiratory rate
4. Decreased blood pressure
Page Ref: 312
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
24) The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. What should the nurse do when administering this medication?
1. Use an infusion pump.
2. Administer with PVC tubing.
3. Use within 8 hours of reconstitution.
4. Allow the patient to get out of bed only with assistance.
Page Ref: 312
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
25) A patient with a traumatic brain injury is being evaluated for brain death. Which finding should the nurse expect in this patient? Select all that apply.
1. Absence of gag or corneal reflex
2. Absence of oculovestibular reflex
3. Apnea with PaCO2 of 66 mmHg
4. Toxic metabolic disorders
5. Response to deep stimuli
Page Ref: 301
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
26) The spouse of a patient with a severe head injury believes the patient is going to recover because of making movements without stimulation. What should the nurse explain to the spouse?
1. "With head injuries, the patient can continue to make movements, but these are reflexes that do not reflect brain function."
2. "Your spouse will likely recover in time."
3. "As long as oxygen gets to the brain, the patient will recover."
4. "Those movements indicate that the brain is dead."
Page Ref: 301
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Grief and Loss
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
27) A patient is brought to the emergency department with gunshot wounds to the abdomen and lower extremities. To protect the chain of evidence for these injuries, what should the nurse do?
1. Remove the patient's clothing and place in a breathable bag.
2. Cover the patient's hands with plastic bags.
3. Cut off the patient's clothing and bathe the skin and wounds as soon as possible.
4. Place clothing and other patient items on a bedside table and have a nursing assistant remove them when possible.
Page Ref: 298
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Management of Care
Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: V.6. Explore the impact of sociocultural, economic, legal and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
28) An adult patient who has died from traumatic injuries is an organ donor. What should the nurse do when caring for this patient?
1. Maintain systolic blood pressure of 90 mmHg.
2. Keep oxygen saturation level at 75%.
3. Administer intravenous fluids to maintain a urine output of 25 mL per hour.
4. Perform external cardiac compressions to achieve a heart rate of 60 beats per minute.
Page Ref: 302
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Management of Care
Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: V.6. Explore the impact of sociocultural, economic, legal and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
29) A patient with traumatic injuries has lost approximately 300 mL of blood. What should the nurse expect to assess in this patient?
1. Slight increase in heart rate
2. Nonpalpable peripheral pulses
3. Narrowing pulse pressure
4. Increase in blood glucose level
Page Ref: 303, 306
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
30) The nurse wants to calculate a patient's mean arterial pressure. Which vital sign measurement should the nurse use to make this calculation?
1. Blood pressure
2. Temperature
3. Respirations
4. Heart rate
Page Ref: 303
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
31) The nurse is providing medications to increase a patient's systemic vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion?
1. Mean arterial pressure reaches 60 mmHg.
2. Mean arterial pressure reaches 90 mmHg.
3. Blood pressure reaches 120/80 mmHg.
4. Urine output is 10 mL per hour.
Page Ref: 303
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
32) A patient has an estimated blood loss of 2 L and a mean arterial pressure ranging between 30 and 40 mmHg. If this patient's hemodynamic status is not corrected, what should the nurse realize can occur?
1. Failure of sodium-potassium pump
2. Cells shrinking
3. Full and bounding peripheral pulses
4. Metabolic alkalosis
Page Ref: 304
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
33) A patient who sustained a traumatic injury several days ago is hypotensive, oliguric, and has cool, pale skin and acidosis. For which type of shock should the nurse plan care for this patient?
1. Hypovolemic
2. Cardiogenic
3. Septic
4. Anaphylactic
Page Ref: 307
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
34) The nurse suspects that a patient with a myocardial infarction is developing cardiogenic shock. What manifestation did the nurse assess to come to this conclusion?
1. Jugular vein distention
2. Warm extremities
3. Laryngospasm
4. Urticaria
Page Ref: 308
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
35) A patient is diagnosed with a pneumothorax. Which type of shock is this patient at risk for developing?
1. Obstructive
2. Hypovolemic
3. Cardiogenic
4. Neurogenic
Page Ref: 309
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; 1. Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
36) An older patient is diagnosed with E. coli in the bloodstream. If not treated, this patient is at risk for developing which types of shock?
1. Distributive
2. Obstructive
3. Hypovolemic
4. Anaphylactic
Page Ref: 309
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
37) A patient is admitted with severe facial injuries from a motor vehicle crash. For what should the nurse first assess this patient?
1. Signs of stridor, cough, or respiratory distress
2. Blood pressure
3. Need for suctioning
4. Loose teeth or obvious problems with the mouth
Page Ref: 298
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
38) A female patient who was raped 6 months ago seeks treatment for posttraumatic stress disorder. Which manifestation should the nurse expect to assess in this patient?
1. Severe nightmares related to the event
2. Absence of anger or shock
3. Avoiding drug and alcohol use
4. Has a very supportive family
Page Ref: 300
Cognitive Level: Analyzing
Client Need & Sub: Psychosocial Integrity: Crisis Intervention
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
39) The nurse is planning care for a patient diagnosed with shock. Which intervention should the nurse include to address this patient's problem of anxiety?
1. Reducing stimuli and medicating for pain
2. Assessing blood pressure and heart rate
3. Monitoring central venous pressure
4. Assessing bowel sounds
Page Ref: 315-316
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Stress Management
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
40) The nurse identifies the problem of impaired physical mobility in a patient hospitalized with traumatic injuries. Which intervention should the nurse identify as appropriate for this patient?
1. Provide active range-of-motion exercises to affected extremities every 8 hours.
2. Turn and reposition every hour.
3. Remove anti-embolic stockings for 3 hours every shift.
4. Administer tetanus toxoid.
Page Ref: 299
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
41) A patient is admitted with trauma to the integumentary system. Which type of skin trauma should the nurse prepare to assess? Select all that apply.
1. Cutaneous
2. Abrasion
3. Laceration
4. Contusion
5. Keloid
Page Ref: 291
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.
42) A trauma patient is being assessed with the Trauma and Injury Severity Score (TRISS) system. What assessment data should the nurse use with this scoring system? Select all that apply.
1. Diastolic blood pressure
2. Heart rate
3. Glasgow coma scale
4. Systolic blood pressure
5. Respiratory rate
Page Ref: 293
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
43) A patient is to receive nitroglycerin (Tridil) 10 mcg/min. The medication strength is 50 mg/250 mL. The IV rate should be ________ mL/min. Record your answer rounding to the nearest whole number.
Page Ref: 312
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
44) A patient has received 145 mL of blood and complains of chills. For what should the nurse assess this patient? Select all that apply.
1. Bradypnea
2. Urticaria
3. Fever
4. Hypertension
5. Lumbar pain
Page Ref: 297
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.
45) A patient in hypovolemic shock is receiving an intravenous colloid solution (plasma expander). Which assessment finding indicates to the nurse that the infusion rate should be reduced? Select all that apply.
1. Prothrombin time of 13.5 seconds
2. Jugular vein distention
3. Tenting of the skin
4. Increased central venous pressure
5. Auscultation of crackles and wheezes
Page Ref: 313
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
46) Emergency personnel are preparing to complete an on-the-scene rapid assessment of a victim of a motor vehicle crash. In which order should the victim's assessment be completed? Place the assessments in order of importance.
Choice 1. Assessment for obvious injuries
Choice 2. Vital signs and patient history
Choice 3. Airway and breathing assessment
Choice 4. Circulation assessment
Choice 5. Level of consciousness and pupillary function
Page Ref: 293
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
47) A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient? Place in order the steps of the process.
Choice 1. Stop the transfusion and notify the healthcare provider
Choice 2. Compare the blood slip with the unit of blood
Choice 3. Assess vital signs and associated manifestations
Choice 4. Save the blood bag and tubing for laboratory analysis
Choice 5. Collect urine and venous blood samples according to policy
Page Ref: 297
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
48) The nurse is concerned that a patient with traumatic chest injures is developing respiratory distress. What assessment finding led the nurse to come to this conclusion? Select all that apply.
1. Combative behavior
2. Absent breath sounds in left lower lobe
3. Pedal and popliteal pulses weak and irregular
4. Temperature raised 2 degrees over the last 4 hours
5. Oxygen saturation 86% on 40% oxygen face mask
Page Ref: 298-299
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Integrity
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
49) An adolescent is experiencing anaphylactic shock after being stung by a swarm of bees. Which medication should the nurse anticipate providing to this patient? Select all that apply.
1. Diuretics
2. Antibiotics
3. Epinephrine
4. Beta2-agonists
5. Antihistamine
Page Ref: 312
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; 1. Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.
MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.
50) A patient with thoracic injuries sustained in a multivehicle crash is demonstrating an alteration in perfusion. What should the nurse do to help this patient? Select all that apply.
1. Auscultate lung sounds.
2. Measure blood pressure.
3. Measure central venous pressure.
4. Reduce rate of intravenous fluids.
5. Assess for jugular vein distention.
Page Ref: 315
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.
Document Information
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Chapter 9 Nursing Care Of Patients In Pain
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Chapter 10 Nursing Altered Fluid Electrolyte
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Chapter 11 Nursing Care Of Patients Experiencing Trauma And Shock
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Chapter 12 Nursing Care Of Patients With Infections And Inflammation
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Chapter 13 Nursing Care Of Patients With Altered Immunity
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