Questions and Answers
What is the primary factor that can exacerbate SLE?
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
A patient with a 30% burn injury to her lower extremities is brought to the emergency department. Which intervention should the nurse perform first?
A patient is diagnosed with hyperglycemic hyperosmolar nonketotic syndrome. What should the nurse prepare to initiate first?
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A patient is bleeding profusely from a deep laceration on his left lower forearm. What should the nurse perform first?
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A patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. What is the depth of the burn?
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A patient is experiencing septic shock. What should the nurse prioritize?
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A patient is experiencing symptoms of stroke. What should the nurse prioritize?
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A patient is experiencing hemorrhagic shock. What should the nurse prioritize?
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A patient is triaged in the emergency department with a burn injury. What should the nurse prioritize?
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Study Notes
Symptoms and Assessment
- Sudden loss of consciousness, muffled heart sounds, and paradoxical chest wall movement with respirations are symptoms of a critical condition.
- Diminished or absent breath sounds on the affected side may indicate a lung-related issue.
Multiple Organ Dysfunction Syndrome (MODS)
- Providing clear information and emotional support to the family is a priority when caring for a patient with MODS.
- Preparing the family for a long recovery process and educating them about the treatment plan are also essential.
Diabetes Mellitus
- Diaphoresis, palpitations, and shakiness are symptoms that may indicate hypoglycemia.
- Hot, dry skin, polyuria, and fruity breath odor are symptoms that may indicate hyperglycemia.
Stroke
- Determining when the patient was last fully functional is crucial in assessing the prognosis of a hemorrhagic stroke.
- Time is a critical factor in determining the course of treatment for an ischemic stroke.
Burn Care
- An escharotomy is a surgical procedure that involves removing dead tissue to prevent further complications.
- Fluid replacement is inadequate if the patient's mean arterial pressure (MAP) is low, such as 55 mmHg.
Septic Shock
- Inadequate fluid replacement is indicated by a low MAP, such as 55 mmHg.
- The highest priority in caring for a patient who has been in a house fire is managing the airway.
Heart Failure
- Excess fluid volume is a priority nursing diagnosis for a patient with acute exacerbation of chronic heart failure.
Digoxin Toxicity
- Nausea, blurred and yellow vision, and confusion are symptoms that may indicate digoxin toxicity.
Sepsis Risk
- Presence of a permanent urinary catheter, such as a suprapubic catheter, increases the risk of sepsis.
Diabetic Ketoacidosis (DKA)
- Stress, infection, and sunlight can exacerbate systemic lupus erythematosus (SLE) in a patient with DKA.
Chest Drainage System
- Constant bubbling in the water-seal chamber of a closed chest drainage system indicates an air leak.
Burn Injury
- The first intervention for a patient with a 30% burn injury is to administer IV fluids.
Hyperglycemic Hyperosmolar Nonketotic Syndrome
- The nurse would immediately prepare to initiate an intravenous infusion of normal saline for a patient with this condition.
Wound Care
- Applying direct pressure to a deep laceration on the forearm is the first action the nurse should perform.
Burn Depth
- A burn that involves the epidermis, dermis, and muscle and bone is classified as a deep burn.
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Description
This quiz assesses the nurse's priority action when caring for a patient with multiple organ dysfunction syndrome (MODS) due to shock. The patient is in the ICU and requires immediate attention.
