Situational Questions MS

8/12/2019 Situational Questions MS

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Jaycel Anne Jalandoni

BSN-2a1

1. A 30-year-old homemaker fell asleep while smoking a cigarette. She sstained se!ere "rnsof the face#neck# anterior chest# and "oth arms and hands. $sing the rle of nines# which is the

"est estimate of total "ody-srface area "rned%

A. 1&'

B. 22'

(. 31'

). *0'

Answer: (C) 31%Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9%

head; 9% each upper extremity; !%" front chest and abdomen; !% entire bac#; !% each

lower extremity and % perineum$

2. Nrsing care planning is "ased on the knowledge that the first 2*-*& hors post-"rn arecharacteri+ed "y,

A. An increase in the total !olme of intracranial plasma

B. cessi!e renal perfsion with diresis

(. /lid shift from interstitial space

). /lid shift from intra!asclar space to the interstitial space

Answer: (D) Fluid shift from intravascular space to the interstitial space

his period is the burn shoc# stage or the hypo&olemic phase$ issue in'urycauses &asodilation that

results in increase capillary permeability ma#ing fluids shift from the intra&ascular to the interstitial

space$ his can lead to a decrease in circulating blood &olume or hypo&olemia which decreases renal

perfusion and urine output$

3. A nrse is directed to administer a hypotonic intra!enos soltion. ooking at the following

la"eled soltions# she shold choose

A. 0.*' Na(lB. 0.' Na(l

(. )

). )NSS

Answer: (A) 0.!% "aCl

(ypotonic solutions li#e )$*+% Nal has a lower tonicity that the blood; )$9% Nal and -+. are


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isotonic solutions with same tonicity as the blood; and -+N// is hypertonic with a higher tonicity thab

the blood$

*. A ma4or goal for the client dring the first *& hors after a se!ere "m is to pre!ent

hypo!olemic shock. 5he "est indicator of ade6ate flid "alance dring this period is

A. le!ated hematocrit le!els.

B. $rine otpt of 30 to 0 ml7hr.

(. (hange in le!el of consciosness.

). stimate of flid loss throgh the "rn eschar.

Answer: (#) $rine output of 30 to !0 mlhr.

(ypo&olemia is a decreased in circulatory &olume$ his causes a decrease in tissue perfusion to the

different organs of the body$ 0easuring the hourly urine output is the most 1uantifiable way of

measuring tissue perfusion to the organs$ Normal renal perfusion should produce ml2#g of 3.2min$

4n output of 5)"+) ml2hr is considered ade1uate and indicates good fluid balance$

. (hemical "rn of the eye are treated with

A. local anesthetics and anti"acterial drops for 2* 8 39 hrs.

B. hot compresses applied at 1-minte inter!als

(. /lshing of the lids# con4ncti!a and cornea with tap or prefera"ly sterile water

). cleansing the con4ncti!a with a small cotton-tipped applicator

Answer: (C) Flushin& of the lids' conunctiva and cornea with tap or preferal* sterile

water

6rompt treatment of ocular chemical burns is important to pre&ent further damage$ 7mmediate tap"

water eye irrigation should be started on site e&en before transporting the patient to the nearest

hospital facility$ 7n the hospital, copious irrigation with normal saline, instillation of local anesthetic

and antibiotic is done$

9. )ennis recei!es a "lood transfsion and de!elops flank pain# chills# fe!er and hematria. 5he

nrse recogni+es that )ennis is pro"a"ly eperiencing,

A. An anaphylactic transfsion reaction

B. An allergic transfsion reaction

(. A hemolytic transfsion reaction

). A pyrogenic transfsion reaction

Answer: (C) A hemol*tic transfusion reaction

his results from a recipient8s antibodies that are incompatible with transfused R38s; also called type


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77 hypersensiti&ity; these signs result from R3 hemolysis, agglutination, and capillary plugging that

can damage renal function, thus the flan# pain and hematuria and the other manifestations$

:. 5he nrse applies mafenide acetate ;Slfamylon cream< to (lara# who has second and third

degree "rns on the right pper and lower etremities# as ordered "y the physician. 5hismedication will,

A. =nhi"it "acterial growth

B. >elie!e pain from the "rn

(. ?re!ent scar tisse formation

). ?ro!ide chemical de"ridement

Answer: (A) +nhiit acterial &rowth

/ulfamylon is effecti&e against a wide &ariety of gram positi&e and gram negati&e organisms includinganaerobes

&. /orty-eight hors after a "rn in4ry# the physician orders for the client 2 liters of =@ flid to "e

administered 612 h. 5he drop factor of the t"ing is 10 gtt7ml. 5he nrse shold set the flow to

pro!ide,

A. 1& gtt7min

B. 2& gtt7min

(. 32 gtt7min

). 39 gtt7min

Answer: (#) ,- &ttmin

his is the correct flow rate; multiply the amount to be infused ))) ml by the drop factor ) and

di&ide the result by the amount of time in minutes hours x elie!e pain and promote rapid epitheliali+ation

). /re6ently "e sed concrrently with topical antimicro"ials.

Answer: (C) elieve pain and promote rapid epitheliali/ation

he graft co&ers ner&e endings, which reduces pain and pro&ides a framewor# for granulation that

promotes effecti&e healing$


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10. hile preparing to discharge an &-month-old infant who is reco!ering from gastroenteritis

and dehydration# the nrse teaches the parents a"ot their infants dietary and flid

re6irements. 5he nrse shold inclde which other topic in the teaching session%

a. Nrsery schools

". 5oilet 5raining

c. Safety gidelines

d. ?reparation for srgery

Answer: (C) Safety guidelines

5he nrse always shold reinforce safety gidelines when teaching parents how to care for theirchild. By gi!ing anticipatory gidance the nrse can help pre!ent many accidental in4ries. /or

parents of a -month-old infant# it is too early to discss nrsery schools or toilet training.

Becase srgery is not sed gastroenteritis# this topic is inappropriate.

11. hen caring for an 11-month-old infant with dehydration and meta"olic acidosis# the nrse

epects to see which of the following%

a. A redced white "lood cell cont

". A decreased platelet cont

c. Shallow respirations

d. 5achypnea

Answer: (D)Tachypnea

5he "ody compensates for meta"olic acidosis !ia the respiratory system# which tries to

eliminate the "ffered acids "y increasing al!eolar !entilation throgh deep# rapid respirations#

altered white "lood cell or platelet conts are not specific signs of meta"olic im"alance.

12. ?atrick# a healthy adolescent has meningitis and is recei!ing =.@. and oral flids. 5he nrse

shold monitor this clients flid intake "ecase flid o!erload may case,

a. (ere"ral edema

". )ehydration

c. eart failre

d. ypo!olemic shock


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Answer: (A) Cerebral edema

Becase of the inflammation of the meninges# the client is !lnera"le to de!eloping cere"ral

edema and increase intracranial pressre. /lid o!erload wont case dehydration. =t wold "e

nsal for an adolescent to de!elop heart failre nless the o!erhydration is etreme.

ypo!olemic shock wold occr with an etreme loss of flid of "lood.

13. An adlt with chronic renal failre is recei!ing peritoneal dialysis. is acid-"ase "alance and

electrolyte le!els are now within normal limits. is hemoglo"in is .2 and his hematocrit is 30.

5he most likely case of his anemia is,

a. hemodiltion secondary to flid retention.

". eating insfficient protein de to taste changes that occr with dialysis.

c. failre of his kidneys to prodce the hormone necessary to stimlate "one marrow to prodce

red "lood cells.

d. hemolysis of red "lood cells as they mo!e past the mem"rane containing the dialysis

soltion.

Answer: (C) failure of his kidneys to produce the hormone necessary to stimulate bone

marrow to produce red blood cells.

emodiltion can prodce a drop in hematocrit. owe!er# if the case of the decrease in

hematocrit were flid retention# one wold epect to find corresponding decreases in serm

sodim. =f the dialysis has corrected the electrolyte "alance# it is nlikely that the client wold

retain sfficient flid to case this drop in hematocrit. emodiltion does not sally prodce

sch a drop in hemoglo"in. 5he case of anemia in persons with chronic renal failre is lack of

erythropoietin. rythropoietin prodced "y the kidneys is necessary to stimlate the "one

marrow to prodce red "lood cells. =n chronic renal failre this hormone is not prodced.

emolysis does not occr with peritoneal dialysis "ecase red "lood cells do not mo!e otside

the clients own "lood !essels# so there are no mechanical forces to harm them.

1*. 5he nrse is assessing a client admitted in ketoacidosis. 5he nrse can epect the clients

skin to "e,

a. clammy.

". flshed.

c. diaphoretic.

d. silky.

Answer: () flushed

(ool# clammy skin is seen in hypoglycemia. Cetoacidosis cases dehydration that reslts in

flshed# dry skin. )iaphoresis is seen in hypoglycemia. Silky skin is not seen in ketoacidosis.


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1. A clients nrsing diagnosis is )eficient /lid @olme related to ecessi!e flid loss. hich

action related to the flid management shold "e delegated to a nrsing assistant%

a. Administer =@ flids as prescri"ed "y the physician.

". ?ro!ide straws and offer flids "etween meals.

c. )e!elop plan for added flid intake o!er 2* hors

d. 5each family mem"ers to assist client with flid intake

A!S"#$: () %ro&ide straws and offer fluids between meals.

5he nrsing assistant can reinforce additional flild intake once it is part of the care plan.

Administering =@ flids# de!eloping plans# and teaching families re6ire additional edcation and

skills that are within the scope of practice for the >N.

19. 5he client also has the nrsing diagnosis )ecreased (ardiac Dtpt related to decrease

plasma !olme. hich finding on assessment spports this nrsing diagnosis%

a. /lattened neck !eins when client is in spine position

". /ll and "onding pedal and post-ti"ial plses

c. ?itting edema located in feet# ankles# and cal!es

d. Shallow respirations with crackles on ascltation

A!S"#$: (A) 'lattened neck &eins when client is in supine position

Normally# neck !eins are distended when the client is in the spine position. 5he !eins flatten asthe client mo!es to a sitting position. 5he other three responses are characteristic of cess

/lid @olme.

1:. 5he nrsing care plan for the client with dehydration incldes inter!entions for oral health.

hich inter!entions are within the scope of practice for the ?N7@N "eing sper!ised "y the

nrse% ;(hoose all that apply.emind client to a!oid commercial mothwashes.

". ncorage moth rinsing with warm saline.

c. Assess lips# tonge# and mcos mem"ranes

d. ?ro!ide moth care e!ery 2 hors while client is awake

e. Seek dietary conslt to increase flids on meal trays.

A!S"#$ A C D


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5he ?N7@Ns scope of practice and edcational preparation incldes oral care and rotine

o"ser!ation. State practice acts !ary as to whether ?N7@Ns are permitted to perform

assessment. 5he client shold "e reminded to a!oid most commercial mothwashes that

contain alcohol# a drying agent. =nitiating a dietary conslt is within the pr!iew of the >N or

physician.

1&. 5he physician has written the following orders for the client with cess /lid !olme. 5he

clients morning assessment incldes "onding peripheral plses# weight gain of 2 ponds#

pitting ankle edema# and moist crackles "ilaterally. hich order takes priority at this time%

a. eight client e!ery morning.

". Eaintain accrate intake and otpt.

c. >estrict flid to 100 m per day

d. Administer frosemide ;asi< *0 mg =@ psh

A!S"#$: (D) Administer furosemide (asi*) +, mg - push

Bilateral moist crackles indicate flid-filled al!eoli# which interferes with gas echange.

/rosemide is a potent loop diretic that will help mo"ili+e the flid in the lngs. 5he other

orders are important "t not rgent.

1. 5he clients potassim le!el is 9.: m67. hich inter!ention shold yo delegate to the

stdent nrse nder yor sper!ision%

a. Administer Cayealate 1 g orally

". Administer spironolactone 2 mg orally

c. Assess (F strip for tall 5 wa!es

d. Administer potassim 10 m6 orally

A!S"#$: (A ) Administer /aye*alate 01 g orally

5he clients potassim le!el is high ;normal range 3.-.0


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Situational Questions MS