A client was brought to ER who sustained a burn injury from opening

the radiator of the overheating truck he was driving. His anterior torso,
the anterior of both arms are the areas affected. What is the total body
surface area burned?
A. 9%
B. 18%
C. 27%
D. 36%
C. 27%

Rationale:
18% (anterior torso) + 4.5 (anterior 1st arm) + 4.5 (anterior 2nd arm)=
27% TBSA
Upon obtaining the TBSA, and with the patient weighing 145 lbs. how
many ml of fluid would the patient receive in a 24 hours fluid
rescucitation?
A. 7,128ml
b. 4,752ml
c. 9,504ml
d. 10,054ml
A. 7,128ml

Rationale: 145lbs./2.2= 65.9kg

27 TBSA x 66kg x 4ml= 7,128 ml/hr
How many ml of lactated ringer's solution should the patient receive
every hour for the first 8 hours?
A. 891ml/hr
b. 454 ml/hr
c. 1188 ml/hr
d. 1256 ml/hr
e. 3,564 ml/hr
E. 3,564

Rationale: 7128ml/2= 3,564 m/hr

During the first 24-48 hours of your care to a burn client, you would be
most concerned with?
A. Severe pain
B. Skin integrity
C. Disturbed body image
D. Psychotherapy
A. Severe pain

Rationale:
Severe pain-Emergent phase
Nursing Care: ◎ Soaking the burn with cool H2O (relieves pain & limit
local tissue edema)

Skin integrity- Acute/Intermediate & Rehabilitative phase

Disturbed body image- rehabilitative phase
Psychotherapy- rehabilitative phase
Which nursing care would you be most concerned during the acute
phase of the burn injury?
A. Fluid volume excess
B. Fluid volume deficit
C. Altered body image
D. Skin Integrity
A. Fluid volume excess

Rationale: Your main assessment for acute/intermediate is the central

venous pressure or checking the client's fluid status. Due to Changes in
capillary permeability & return of osmotic pressure bring about
diuresis & increased urine output. If renal & Cardiac functions do not
return to normal, the added fluid volume which prevented
hypovolemia shock may produce SS of CHF
Skin integrity problem is focused in what phase of the burn injury?
A. Acute phase
B. Rehabilitative phase
C. Emergent phase
D. Intermediate phase
 C. Emergent phase

Rationale: Emergent phase if focused on skin integrity (cleaning the

would with aseptic technique to avoid contamination), relieving pain
(soaking the burn with H2O), and assessing ABCDE's
Acute & Intermediate are the same phase. This phase is focused on
assessing the client's fluid status.
Rehabilitative phase is focused on rehabilitating after the burn &
returning the client to their preinjury life.
A client was burned due to a heating steam. Injury involves dermis,
epidermis to hypodermics, red to pink and painful. What degree of
burn did the client sustained?
A. first degree
b. Second degree
c. Third degree
d. Fourth degree
B. Second degree

Rationale:
Second Degree
◎ Mottled, red, painful
◎ Heals in 14-20 days
◎ Superficial burn heals causing pigmentation
◎ Deep burn heals causing scarring & pigmentation
A patient has a burn in his chest & face and is having strider. What
would be your priority nursing action?
A. Obtain an IV line
b. Give 100% oxygen is a non-rebreather mask
c. Take history as to how the incident happened
d. Irrigate the would with saline solution
B. Give 100% oxygen is a non-rebreather mask

Rationale: The client has an inhalation burn injury during the emergent
phase. The focus for the client is to assess ABC's & if the patient is able
to breathe properly.
 Dressing the wound of the burnt area is included in the plan of care of
the nurse caring for a burned client. What topical dressings would most
likely be applied on the burned area?
A. Betadine
B. 70% isopropyl alcohol
C. Silver sulfadizine (Silvadene)
D. Terramycin
C. Silver sulfadizine (Silvadene)

Rationale: Topical antibiotics for burns:

• silver sulfadiazine (Silvadene),
• Mafenide acetate (sulfamylon),
• Silver nitrate, which can be used in an aqueous solution of 0.5% or
Acticoat
On the third post-burn day, the nurse finds that the client's hourly
urine output is 26ml. He nurse should continue to assess the client &
notify the doctor for an order to:
A. Decrease the rate of the intravenous infusion
B. Change the type of IV fluid being administered
C. Change the urinary catheter
D. Increase the rate of intravenous infusion
D. increase the rate of intravenous infusion

Rationale: The urine output should be maintained between 30-

50ml/hr. An increase of IV infusion may prevent acidosis from
occurring.
A. Decrease the rate of the IV infusion- would decrease urine output
B. Change the type of IV fluid administered-no benefit
C. Change the urinary catheter-increase the risk of infection
A 53-year-old male is admitted to the ER. The patient is a farmer and
was out in a field spraying an insecticide that is an organophosphate
agent. The patient is experiencing severe muscle tremors, drooling, and
disapproves is. The diagnosis is organophosphate poisoning. What
medication below do you anticipate the physician to order for this
patient?
A. Atropine
 B. Glucagon
C. Digibind
D. Diazepam
A. Atropine

Rationale: Organophosphate poisoning damages

acetylecholinesterase,which control nerve signals in your body.
Atropine competes with acetylcholine at the muscadine receptors
Dose: 2-5mg, IV for adults
A client is suspected of carbon monoxide poisoning free seeing
crawling on the floor from a building with fire, what intervention
should be initiated first?
A. wash the wound site from burn
B. Give oxygen at a low rate
C. give 100% oxygen in non-rebreather mask
D. Initiate an IV line for the fluids
C
13. Antidote for Paracetamol
A. Acetylcysteine
B. Cobalamin
C. Phystigmine
D. Glucose
A. Acetylcysteine

Rationale: Safe & effective antidote, prevents serious hepatic injury.

Which therapeutic agent is called a universal antidote?
A. Protamine sulfate
B. Glucose
C. Cobalamin
D. Activated charcoal
D. Activated charcoal

Rationale: used for majority of poisoning because of its ability to

 prevent the absorption of most toxic agents from the GIT & enhance
elimination of some agents already absorbed.
Burns which condition does hyperbaric therapy be administered?
A. Heatstroke
B. Decompression sickness
C. Lead poisoning
D. Hyperthermia
D. Decompression sickness

Rationale: Hyperbaric therapy is applicable to CO2 poisoning, cyanide

poisoning, crush injuries, gas gangrene, decompression sickness
A patient in an industrial factory making ceramics accidentally fell on
the big pot of boiling after where ceramics are placed. He sustained a
severe burn in his posterior torso, anterior and posterior of right arm,
and anterior of both legs. he patient weighs 150 lbs. Compute for the
TBSA and Parkland formula for his fluid rescucitation.
Total BSA= 45%
Fluid Resuscitation= 12,240 ml/hr

Rationale:
TBSA- posterior torso (18%), anterior + posterior of right arm (9%), and
anterior of both legs (18%).
18 + 9 + 18= 45 TBSA

Fluid resuscitation:
45% x 68kg x 4ml= 12,240ml/hr
What is the key factor in describing any type of the shock?
A. Hypoxemia
B. Hypotension
C. Vascular collapse
D. Inadequate tissue perfusion
d. inadequate tissue perfusion

Rationale: Althrough all of the factors may be present, regardless of the

 cause, the end result is inadequate supply of oxygen and nutrients to
body cell from inadequate tissue perfusion.
When shock occurs in a patient with pulmonary embolism or
abdominal compartment syndrome, what type of shock would that be?
A. Distributive shock
B. Obstructive shock
C. Cardiogenic shock
D. Hypovolemic shock
B. Obstructive shock

Rationale: Obstructive shock occurs when a physical obstruction

impedes the filling or outflow of blood resulting in reduced CO.
Distributive shock is evident with massive vasodilation & impaired
cellular metabolism (neurogenic shock) or increased capillary
permeability (anaphylactic shock). Cardiogenic shock occurs when
systolic or diastolic dysfunction of the heart's pumping action results in
reduced CO. Hypovolemic shock is the absolute or relative loss of blood
or fluid.
What physical problems would precipitate Hypovolemic shock? SATA
A. Burns
B. Ascites
C. Vaccines
D. Insect bites
E. Hemorrhage
F. Ruptured spleen
A. Burns
B. Ascites
E. Hemorrhage
F. Ruptured spleen

Rationale: Hypovolemic shock occurs when there is a loss of

intravascular fluid volume from fluid loss (e.g hemorrhage, or severe
vomiting and diarrhea), fluid shift (eg. burns or ascites) or internal
bleeding (with ruptured spleen). Vaccines and insect bites would
precipitate the anaphylactic type of distributive shock
 A 70-year-old patient is malnourished, has a history of type 2 diabetes
mellitus, and is admitted from the nursing home with pneumonia and
tachypnea. For which kind of shock should the nurse closely monitor
this patient?
A. Septic shock
B. Neurogenic shock
C. Cardiogenic Shock
D. Anaphylactic shock
A. Septic Shock

Rationale: Older adults with chronic diseases & malnourished or

debilitated patients are at risk of developing septic shock, especially
when they have an infection (eg pneumonia, UTI) or in dwelling lines or
catheters. Fevers hypothermia, tachycardia, tachypnea, altered mental
status, significant edema or hyperglycemia without diabetes are also
criteria for diagnosis of sepsis.
In the compensatory stage of Hypovolemic shock, to what organs does
blood flow decrease after the sympathetic nervous system activates
the a-adrenergic stimulation (SATA)
A. Skin
B. Brain
C. Heart
D. Kidney
E. GI
A. Skin, D. Kidneys, E. GI

Rationale: After sympathetic nervous system (SNS) activation of

vasoconstriction, blood flow to nonvital organs, such as skin, kidneys,
and the gastrointestinal (GI) tract is diverted or shunted to the most
essential organs of the heart and brain. The patient will feel cool and
clammy, the renin-angiotensin aldosterone system will be activated,
and the patient may develop a paralytic ileus.
As the body continues to try to compensate for Hypovolemic shock,
there is increased angiotensin II from the activation of the renin-
angiotensin-aldosterone system. What physiologic change occurs
related to the increased angiotensin II?
 A. Vasodilation
B. Decreased BP & CO
C. Aldosterone release results in sodium & water excretion
D. Antidiuretic hormone (ADH) release increases water reabsorption
D. Antidiuretic hormone (ADH) release increases water reabsorption

Rationale: Angiotensin II vasoconstricts both arteries and veins, which

increases BP. It stimulates
aldosterone release from the adrenal cortex, which results in sodium
and water reabsorption and
potassium excretion by the kidneys. The increased sodium raises serum
osmolality and stimulates the pituitary gland to release antidiuretic
hormone (ADH), which increases water reabsorption, which further
increases blood volume, leading to an increase in BP and CO.
The patient is in the compensatory stage of shock. What manifestations
indicate this to this nurse? SATA
A. Pale & cool
B. Unresponsive
C. Lower BP than baseline
D. Moist crackles in the lungs
E. Hyperactive bowel sounds
F. Tachypnea & tachycardia
A. Pale & cool
C. Lower BP than baseline
F. Tachypnea & tachycardia

Rationale: In the compensatory stage of shock the patient's skin will be

pale and cool (α-adrenergic stimulation). There may also be a change in
level of consciousness, but the person will be
responsive, the BP will be lower than baseline, bowel sounds will be
hypoactive (α-adrenergic
stimulation), and tachypnea and tachycardia (β-adrenergic stimulation)
will occur. Unresponsiveness and moist crackles in the lungs occur in
the progressive stage of shock.
The nurse suspect sepsis as a cause of shock the laboratory test results
indicate
 A. Hypokalemia
B. Thrombocytopenia
C. Decreased hemoglobin
D. Increased blood urea nitrogen (BUN)
B. Thrombocytopenia

Rationale: Thrombocytopenia can occur. When sepsis is the cause of

shock, endotoxin stimulates a cascade of inflammatory responses that
start with the release of tumor necrosis factor (TNF) and
interleukin-1 (IL-1), which stimulate other inflammatory mediators. The
release of platelet activating
factor causes formation of microthrombi and vessel obstruction. There
is vasodilation, increased capillary permeability, neutrophil and platelet
aggregation, and adhesion to the endothelium. The process does not
occur in other types of shock until late stages of shock.
Progressive tissue hypoxia leading to anaerobic metabolism &
metabolic acidosis is characteristic of the progressive stage of shock.
What changes in the heart contribute to this increasing tissue hypoxia?
A. Coronary artery constriction causes decreased perfusion
B. Cardiac vasoconstriction decreased blood flow to pulmonary
capillaries
C. Increased capillary permeability & profound vasoconstriction cause
increased hydrostatic pressure.
D. Decreased perfusion occurs, leading to dysrhythmias, decreased CO
and decreased oxygen deliver to cells.
D. Decreased perfusion occurs, leading to dysrhythmias, decreased CO
an decreased oxygen delivery to cells

Rationale: Decreased myocardial perfusion leads to dysrhythmias and

myocardial ischemia, further decreasing CO and oxygen delivery to
cells. The kidney's renin-angiotensin-aldosterone system activation
causes arteriolar constriction that decreases perfusion. In the lung,
vasoconstriction of arterioles decreases blood flow and a ventilation-
perfusion mismatch occurs. Areas of the lung that are oxygenated are
not perfused because of the decreased blood flow, resulting in
hypoxemia and decreased oxygen for cells. Increased capillary
permeability and vasoconstriction cause increased hydrostatic pressure
that contributes to the fluid shifting to interstitial spaces, but this
is not a change in the heart.
A patient with severe trauma has been treated for Hypovolemic shock.
The nurse recognizes that the patient is in the refractory stage of shock
when what is found during an assessment?
A. A respiratory alkalosis with a pH of 7.46
B. Marked hypotension & refractory hypoxemia
C. Unresponsive ness that responds only to painful stimuli
D. Profound vasoconstriction with absent peripheral pulses
B. Marked hypotension & refractory of hypoxemia

Rationale:
During both the compensatory and progressive stages of shock, the
SNS is activated in an
attempt to maintain CO and SVR. In the refractory stage of shock, the
SNS can no longer
compensate to maintain homeostasis and a loss of vasomotor tone
leading to profound hypotension affects perfusion to all vital organs,
causing increasing cellular hypoxia, metabolic acidosis, and cellular
death. Respiratory alkalosis occurs in early shock. Unresponsiveness
and absent peripheral pulses can occur for many reasons and in earlier
shock.
A patient with acute pancreatitis is experiencing Hypovolemic shock.
Which invitations orders for the patients will the nurse implement
first?
A. Start 1000mL of normal saline at 500mL/hr
B. Obtain blood cultures before staring IV antibiotics.
C. Draw blood for hematology & coagulation factors
D. Administer high-flow oxygen (100%) with a non-rebreather mask
D. Administer high-flow oxygen (100%) with a non-rebreather mask

Rationale: In every type of shock there is a deficiency of oxygen to the

cells, and high-flow oxygen therapy is indicated. Fluids would be
started next, blood cultures would be done before anyantibiotic
therapy, and laboratory specimens could also be drawn.
 What abnormal finding should the nurse expect to find in early
compensatory shock?
A. Metabolic acidosis
B. Increased serum sodium
C. Decreased blood glucose
D. Increased serum potassium
B. Increased serum sodium

Rationale: In early compensatory shock, activation of the renin-

angiotensin-aldosterone system stimulates the release of aldosterone,
which causes sodium reabsorption and potassium excretion by the
kidney, elevating serum sodium levels and decreasing serum potassium
levels. Metabolic acidosis does not occur until the progressive stage of
shock. At this stage compensatory mechanisms become ineffective and
anaerobic cellular metabolism causes lactic acid production. Blood
glucose levels are elevated during the compensatory stage of shock in
response to catecholamine stimulation of the liver, which releases its
glycogen stores in the form of glucose.
A patient with Hypovolemic shock is receiving lactated ringer's solution
for fluid replacement therapy. During the therapy, which laboratory
result is most important for the nurse to monitor?
A. Serum pH
B. Serum sodium
C. Serum potassium
D. Hemoglobin (Hgb) and hematocrit (Hct)
A. Serum pH

Rationale: Lactated Ringer's solution may increase lactate levels, which

a damaged liver cannot convert to bicarbonate. This may intensify the
metabolic lactic acidosis that occurs in progressive shock, necessitating
careful attention to the patient's acid-base balance. Sodium and
potassium levels as well as hemoglobin (Hgb) and hematocrit (Hct)
levels should be monitored in all patients receiving fluid replacement
therapy.
What should be the nurse assess the patient for during administration
of IV nonrepinephrine (Levophed)?
 A. Hypotension
B. Marked diuresis
C. Metabolic alkalosis
D. Decreased tissue perfusion
D. Decreased tissue perfusion

Rationale: As a vasopressor, norepinephrine may cause severe

vasoconstriction, which would further decrease tissue perfusion,
especially if fluid replacement is inadequate. Vasopressors generally
cause hypertension, reflex bradycardia, and decreased urine output
because of decreased renal blood flow. They do not directly affect acid-
base balance.
When administering any vasoactive drug during the treatment of
shock, the nurse should know that what is the goal of therapy?
A. Increasing urine output to 50 ml/hr
B. Constriction of vessels to maintain BP
C. Maintaining a MAP of at least 5 mmHg
D. Dilating vessels to improve issue perfusion
C. Maintaining a MAP of at least 5 mmHg

Rationale: Vasoactive drugs are those that can either dilate or constrict
blood vessels and are used in various stages of shock treatment. When
using either vasodilators or vasoconstrictors, it is important to maintain
a mean arterial pressure (MAP) of at least 65 mm Hg so that adequate
perfusion is maintained. The goal for urine output is ≥0.5 mL/kg/hr.
The other goals would be appropriate only with either vasodilators or
vasoconstrictors, not with all vasoactive drugs.
Identify two medical therapies that are specific to each of the following
types of shock: Cardiogenic
Thrombolytic therapy, angioplasty, emergency revascularization,
Increase CO with inotrope coming agents, reduce workout by dilating
coronary arteries, intra-aortic ballon pump, treat dysrhythmias
Identify two medical therapies that are specific to each of the following
types of shock: Hypovolemic
 Fluid & blood replacement, control of bleeding with pressure, surgery
Identify two medical therapies that are specific to each of the following
types of shock: Septic
Fluid resuscitation, antimicrobial agents, inotropic agents with
vasopressors
Identify two medical therapies that are specific to each of the following
types of shock: Anaphlyactic
Epinephrine, inhaled bronchodilators, colloidal fluid replacement,
diphenhydramine, corticosteroids
Identify four drugs and their actions that are used in treatment of
cardiogenic shock but are not generally used for other types of shock:
Epinephrine (Adrenalin)
Increase contractility of heart & SVR by constricting blood vessels
Identify four drugs and their actions that are used in treatment of
cardiogenic shock but are not generally used for other types of shock:
Dobutamine (Dobutex)
Increase contractility of heart by binding onto beta adrenergic
receptors
Identify four drugs and their actions that are used in treatment of
cardiogenic shock but are not generally used for other types of shock:
Norepinephrine (Levophed)
Increase BP by binding to a & B adrenergic receptors for
vasoconstriction
Identify four drugs and their actions that are used in treatment of
cardiogenic shock but are not generally used for other types of shock:
Amrinone
Increase contractility of heart by inhibiting phosphodiesterase
What is the PRIORITY nursing responsibility In the prevention of
shock?
A. Frequently monitoring all patients' vital signs
B. Using aseptic technique for all invasive procedures
 C. Being aware of the potential for shock in all patient at risk
D. Teaching patient health promotion activities to prevent shock
C. Being aware of the potential for shock in all patient at risk

Rationale: Prevention of shock necessitates identification of persons

who are at risk and a thorough baseline nursing assessment with
frequent ongoing assessments to monitor and detect changes in
patients at risk. Frequent monitoring of all patients' vital signs is not
necessary. Aseptic technique for all invasive procedures should always
be implemented but will not prevent all types of shock.Health
promotion activities that reduce the risk for precipitating conditions,
such as coronary artery disease or anaphylaxis, may help to prevent
shock in only some cases.
Which indicators of tissue perfusion should be monitored in critically ill
patients by the nurse? SATA:
A. Skin
B. Use output
C. LOC
D. Activities of daily living
E. Vital signs, including pulse oximetry
F. Peripheral pulses with capillary refill
A, B, C, E, F

Rationale: Skin (color, temperature, moisture), urine output, level of

consciousness, vital signs (including pulse oximetry), and peripheral
pulses with capillary refill should be monitored to evaluate tissue
perfusion.
Which interventions should be used for anaphylactic shock? SATA
A. Antibiotics
B. Vasodilator
C. Antihistamines
D. Oxygen supplementation
E. Colloid volume expansion
F. Crystalloids volume expansion
 C, D ,E, F

Rationale: Antihistamines, oxygen supplementation, and colloid

volume expansion are used to treat anaphylactic shock. Crystalloids
may also be used. Epinephrine, a vasopressor, is also frequently used.
Only septic shock is treated with antibiotics. Vasodilators and inotropes
are only used for cardiogenic shock. Volume expansion fluids vary with
each type of shock.
A patient in shock has a nursing diagnosis of fear related to severity of
condition and perceived threat of death as manifested by verbalization
of anxiety about condition and fear of death. What is an appropriate
nursing intervention for this patient?
A. Administer anti anxiety agents
B. Allows caregivers to visit as much as possible
C. Call a member of the clergy to visit
D. Inform the patient of the current plan of care and its rationale
D. Inform the patient of current plan of care & its rationale

Rationale: Although some patients in shock may be treated with

antianxiety and sedative drugs to control anxiety and apprehension,
the nurse should always acknowledge the patient's feelings, explain
procedures before they are carried out, and inform the patient of the
plan of care and its rationale. Visits by family may have a therapeutic
effect for some patients but may increase stress in others. Offering to
call a member of the clergy is appropriate, but they should be called
only if the patient requests or agrees to a visit.
Which statement describing systematic inflammatory response
syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS)
accurate?
A. MODS may occur independently from SIRS
B. All patients with septic shock develops MODS
C. The GI system is often the first to show evidence of dons function in
SIRS & MODS
D. A common initial mediator that causes endothelial damage leading
to SIRS & MODS is endotoxins
 D. A common initial mediator that causes endothelial damage leading
to SIRS & MODS is endotoxins

Rationale: A common initial mediator that causes endothelial damage

leading to systemic inflammatory response syndrome (SIRS) and/or
multiple organ dysfunction syndrome (MODS) is endotoxin. MODS
results from SIRS. Not all patients with septic shock develop MODS,
although they do have SIRS. The respiratory system is frequently the
first to show evidence of SIRS and MODS.
What mechanism that can trigger SIRS is related to myocardial
infarction or pancreatitis?
A. Abscess formation
B. Microbial invasion
C. Global perfusion deficits
D. Ischemic or necrotic tissue
D. Ischemic or necrotic tissue

Rationale: The ischemic or necrotic tissue mechanism triggers SIRS with

myocardial infarction,
pancreatitis, and vascular disease. The abscess formation mechanism
occurs with intraabdominal and extremity abscesses. The microbial
invasion trigger is related to bacteria, viruses, fungi, or parasites.
Global perfusion deficits are seen post-cardiac resuscitation and in
shock states.
The patient is admitted with an unusual infection. The nurse knows
that a mechanical tissue trauma that can trigger SIRS will not occur
with this patient because what types of injury cause a mechanical
tissue trauma trigger of SIRS? SATA

A. Burns
B. Fungi
C. Viruses
D. Crush injuries
E. Surgical procedures
A, D, E
 Rationale: Mechanical tissue trauma triggering of SIRS occurs with
burns, crush injuries & surgical procedures. Fungi, viruses, bacteria &
parasites cause microbial invasion triggering which is more likely in this
patient