Metropolitan Community College
NURS 2140
Final Review
Fall 2013
Concepts I Would Review
Types of burns
- Thermal, scald, electrical, radiation,
chemical, inhalation
Shock syndromes
Rule of Nines
Nursing management of shock
Burn depth
- First, second, third/fourth degree
MODS
Fluid resuscitation for clients with burns
Labs used in the evaluation of fluid status
Pain management for clients with burns
Overhydration
Nursing care in each phase of burn treatment
Dehydration
SIRS
Electrolyte imbalances
Four categories of acid/base abnormalities
Role of the lungs in acid/base balance
Hypercarbic drive
Role of the kidneys in acid/base balance
Hypoxic drive
Interpreting ABGs
Complications of infusion therapy
Central lines
PICC lines
Implanted ports
Adventitious breath sounds
Lower airway disorders
Airway obstruction
Intubation
Tracheostomy
Mechanical ventilation
*This is not an all-inclusive list of what will be on the test. This is
however, a great place to start studying.*
Normal pH – 7.35-7.45, PaCO2 – 35-45, HCO3 – 22-28
Uncompensated Phase – 2 abnormal, one still normal
pH
Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis
PaCo2
HCO3
Normal
Normal
Normal
Normal
Partially Compensated – All three are abnormal
pH
PaCo2
HCO3
PaCo2
HCO3
Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis
Fully Compensated Phase – pH is normal
Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis
pH
Normal
Normal
Normal
Normal
1. The nurse is caring for a client with 3rd degree burn injuries over 45% of his body. The
client’s wife asks the nurse “Why does he need those intravenous fluids?” What is the
best response by the nurse?
A.
B.
C.
D.
So he can receive his antibiotics
So we can be sure he keeps enough blood volume
So we have an open line in case his heart stops
So we can rapidly administer his pain medications
2. The client has been running in a long-distance marathon on a very warm day. The client
complains of dizziness and nausea. She is taken to the hospital where she becomes
lethargic. The serum sodium level is 125 mEq/L. What will be the best plan for this
client?
A.
B.
C.
D.
Administer normal saline IV
Administer 0.45% NaCl
Encourage the client to drink fluids
Provide a diet high in sodium
3. When planning care for a client with a partial airway obstruction, which nursing
intervention has the greatest priority?
A.
B.
C.
D.
Ensuring advanced airway equipment is at the bedside
Ensuring the resuscitation team is on standby
Keeping the client calm and relaxed
Providing pain medication around the clock
4. A client diagnosed with active tuberculosis is in a negative pressure room for respiratory
airborne isolation. How long should the nurse maintain the client in this type of isolation?
A.
B.
C.
D.
Until the Mantoux test converts from positive to negative
Until the client has orders for discharge
Until the chest x-ray is normal
Until three consecutive sputum specimens for acid fast bacilli
are negative
5. The nurse is caring for a client who was admitted in respiratory distress. What is the
nurse’s priority action based on this ABG: pH: 7.32, PaCO2: 52, HCO3: 20
A.
B.
C.
D.
Document and continue to monitor
Place the client on oxygen via mask
Call the healthcare provider to report the results
Suction the client using a yankeur
6. During the immediate postburn period, the nurse assesses the client for injuries other than
burns. Which of the following assessments indicates a potential problem?
A. Urine output of 30ml/hour
B. Presence of eschar
C. Presence of edema
D. Coughing
7. The nurse is caring for a client with papillary muscle rupture. When assessing the client,
the nurse is alert to the development of symptoms related to _________ shock?
A.
B.
C.
D.
Septic
Anaphylactic
Cardiogenic
Neurogenic
8. The family of a client in shock asks why the client’s hands are cold. The nurse’s best
response is which of the following?
A. “Blood vessels constrict in shock, which takes blood away
from the hands and feet”
B. “We keep the intensive care unit cool to reduce clients’
metabolic rate”
C. “Your family member has developed a fever and chills”
D. “This happens frequently to clients in shock states”
9. While flushing a central vascular access device, the nurse meets resistance. The nurse
should:
A.
B.
C.
D.
Apply force to the syringe
Report the findings to the physician
Check the clamp on the catheter
Pull the catheter back slightly
10. When caring for a group of patients, which of the following individuals is at risk for
metabolic alkalosis?
A.
B.
C.
D.
A patient with bulimia
A patient undergoing dialysis
A patient with a venous stasis ulcer
A patient with COPD
Answers
1. B
Rationale: Clients with burn injuries lose a great deal of fluid from the injured area. A net
loss of fluids from the body can result in dehydration and shock. IV fluid therapy is used to
maintain blood volume and support blood pressure.
2. A
Rationale: The client is experiencing hyponatremia with lethargy. She needs an isotonic IV
fluid. Oral intake of fluid and food is contraindicated due to her altered mental status. 0.45%
NaCl is hypotonic and will further lower her sodium level.
3. A
Rationale: Whenever a client has the potential to quickly lose the airway, advanced airway
tools such as intubation equipment and tracheotomy supplies should always remain at the
bedside. The resuscitation team, keeping the client calm, and providing pain medication are
needed, but maintaining the airway is priority.
4. D
Rationale: The client should remain in isolation until three consecutive sputum cultures have
tested negative. Until that time and in spite of treatment, there is no certainty that the client is
not infectious. A positive PPD indicates that an individual has been exposed to tuberculosis
and has developed antibodies, so the PPD will not convert back to negative. The chest x-ray
validates the amount of lung involvement; the client may experience chronic changes, such
as nodules. The client should not be discharged without evidence that he or she is no longer
infectious.
5. B
Rationale: In blood gases, normal pH: 7.35−7.45; normal PaCO2: 34−45 mmHg; normal
HCO3: 22−26 mEq/L; so respiratory acidosis occurs when the pH drops below 7.35, the
PaCO2 is >45 mmHg, and the HCO3 is < 22 mmHg. Thus, this client requires oxygen. Once
placed, the nurse can report the results. Suctioning is not indicated. The nurse should
continue to document and monitor, but not until the patient has been placed on oxygen.
6. D
Rationale: Coughing could indicate either an inhalation injury or a cold. Urine output of
30 ml/hour is a normal finding. The presence of eschar and edema are normal manifestations
of burn injuries.
7. C
Rationale: The papillary muscle holds the valves in place and may be damaged during MI,
the most common reason for cardiogenic shock. Anaphylactic shock develops from
hypersensitivity reactions. Neurogenic shock results from spinal cord injury or vasodilatation
below the level of spinal anesthesia, and septic shock results from overwhelming infection.
8. A
Rationale: Vasoconstriction results from catecholamine release, which is a compensatory
mechanism in shock. Cooling measures are used in shock for fever; the ICU is not
purposefully chilled. There is no indication that the client has developed fever and chills.
Stating that cold hands happen frequently does not answer the family member’s question.
9. C
Rationale: The nurse would check the clamp on the catheter because the catheter is clamped
when not in use; unclamping the catheter is necessary to initiate flushing of the catheter.
Applying force to the syringe could result in damage to the catheter or could dislodge a clot.
Pulling the catheter back could result in misplacement of the catheter in the vena cava. The
physician should not be called unless an occlusion is certain.
10. A
Rationale: Metabolic alkalosis is caused by vomiting, diuretic therapy, or NG suction, among
others. A bulimic client may engage in vomiting or indiscriminate use of diuretics. A client
undergoing dialysis has kidney failure, which causes metabolic acidosis. A venous stasis
ulcer does not result in an acid−base disorder. The client with COPD typically has
hypercapnea and respiratory acidosis.