Acute: Integumentary/Musculoskeletal
The ICU burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial thickness burns over half the body. Which client problem is priority? 1. risk for infection 2. ineffective coping 3. Impaired physical mobility 4. Knowledge deficit
1 (Priority)
The nurse should plan to begin rehabilitation efforts for the burn client: 1. immediately after the burn occurred 2. after the clients circulatory status has been stabilized 3. after grafting of the burn wounds has occurred 4. after the clients pain has been eliminated
2 (Rehab efforts are implemented as soon as the clients condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure the client will be able to make the adjustments necessary to return to optimal status of health and independence. It is not possible to completely eliminate the clients pain. pain control is a challenge in burn care.)
The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The nurse documents this assessment finding as expected because the edema is caused by which factor? 1. A decrease in capillary permeability and hypoproteinemia 2. A decrease in capillary permeability and hyperproteinemia 3. An increase in capillary permeability and hypoproteinemia 4. An increase in capillary permeability and hyperproteinemia
3 Rationale: In extensive burn injuries (greater than 25% of total body surface area), the edema occurs in both burned and unburned areas as a result of the increase in capillary permeability and hypoproteinemia. Edema also may be caused by the volume and oncotic pressure effects of the large fluid resuscitation volumes required.
Which factor would have the least influence on the survival and effectiveness of a burn victims porcine grafts? 1. absence of infection in the wounds 2. adequate vascularization in the grafted area 3. immobilization of the area being grafted 4. use of analgesics as necessary for pain relief
4 (Analgesic admin is to keep a burn victim comfortable and is important, but is unlikely to influence graft survival and effectiveness. Absence of infection, adequate vascularization, and immobilization of the grafted area promote an effective graft)
The nurse is caring for a client with deep partial thickness and full thickness burns to the chest area. Which assessment data would warrant notifying the HCP? 1. The client is complaining of severe pain 2. The clients pulse ox is 95% 3. The client has T 100.4, P 100, RR 24, and BP 102/60 4. The clients urinary output is 50 in 2 hrs
4 (F&E is priority in clients with severe burns. Fluid resuscitation must be maintained to keep urine output of min 30 mL/hr WRONGL #3 yes these signs are off, but they are not unusual with severe burns)
Using the Parkland formula calculate the hourly rate of fluid replacement with LR solution during the first 8 hrs for a client weighing 75 kg with a TBSA (total body surface area) burn of 40%. Record your answer using a whole number ___________ mL/h
750 (When calc fluid replacement only use the burned portion of the TBSA. HALF given over 1st 8 hrs. and 1/2 given over next 16 hrs. LR 4 mL x wt in kg x TBSA STep one: 4 x 75 x 40= 12000 mL Step two : 12000/ 8 x 1/2 = 750 mL/hr)
A nurse provides education for a client newly diagnosed with systemic scleroderma. Which information does the nurse include? SATA A. "Regular therapeutic exercise can prevent excessive skin tightening and promote circulation." B. "Your scleroderma symptoms will be treated with medications called corticosteroids." C. "Too much collagen is produced in scleroderma, causing thickened skin and occluded blood vessels." D. "Scleroderma is thought to be caused by a virus or by widespread bacterial infection." E. "Scleroderma is an autoimmune disease that affects skin, blood vessels, muscles, and internal organs."
A. "Regular therapeutic exercise can prevent excessive skin tightening and promote circulation." B. "Your scleroderma symptoms will be treated with medications called corticosteroids." C. "Too much collagen is produced in scleroderma, causing thickened skin and occluded blood vessels." E. "Scleroderma is an autoimmune disease that affects skin, blood vessels, muscles, and internal organs." Explanation Systemic scleroderma (also called systemic sclerosis) is an autoimmune disorder that causes inflammation and sclerosis (hardening) of the skin, muscles, joints, lungs, kidneys, and heart. Treatment includes preventing or treating complications of involved organs. Physical and occupational therapy help maintain function. Drug therapy is limited to relief of symptoms such as pain and Raynaud. Client teaching involves avoiding physical and emotional stress.
The nurse has educated a client on Paget's disease. Which statement by the client indicates good understanding of causative factors? a. "It is caused by lack of calcium in my diet." b. "I probably had a fracture that caused it." c. "This disease occurs because of lack of exercise." d. "I may have a genetic predisposition."
ANS: D Paget's disease has been noted in up to 30% of people with a positive family history. The other responses are not accurate as a cause of Paget's disease.
When evaluating the effectiveness of treatment for a patient who is being treated for Paget's disease with calcitonin (Cibacalcin) and ibandronate (Boniva), the nurse will ask the patient about a. weight loss. b. skeletal pain. c. decreased appetite. d. frequent cough.
Answer: B Rationale: Bone pain is one of the common early manifestations of Paget's disease, and the nurse should ask about improvement in pain levels to determine whether the treatment is effective. Weight loss, anorexia, and frequent cough are not symptoms of Paget's disease. Cognitive Level: Application Text Reference: p. 1690 Nursing Process: Evaluation NCLEX: Physiological Integrity
A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm
C Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.
The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which of the following laboratory values is the best indicator of a need to adjust the nutritional program? 1. glycosuria 2. creatine phosphokinase (CPK) 3. BUN levels 4. hemoglobin 5. serum sodium levels
Correct Answer: 1 Rationale: Glucose in the urine is seen after a major burn injury. It signals the need to reevaluate the patient's nutritional plan. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury dependent upon the fluid status. Serum sodium levels are not indicative of nutritional status.
A nurse is teaching a class of park rangers-in-training about prioritizing care for clients who have received snakebites. Which ranger's statement demonstrates a need for further clarification? a. ''Do not allow the client to ingest any alcohol or caffeine.'' b. ''The extremity should be kept below the level of the heart.'' c. ''The first priority is to move the client to a safe area away from the snake.'' d. ''You should first place a tourniquet above the bite.''
D (If transportation and treatment are delayed, a 2- to 4-cm constricting band may be applied proximal to an extremity wound to slow venom circulation via lymphatic flow. It should not be used as a tourniquet, however. This could worsen local tissue necrosis by retaining venom in the tissues.)
A nurse is caring for a client with frostbite to the toes. After rewarming, which intervention will the nurse implement? Elevate the client's legs on pillows Dangle the client's legs off the side of the bed Rub the client's legs with lotion Place compression stockings on the client's legs
Elevate the client's legs on pillows Rationale:After rewarming, the nurse will elevate the affected extremities to increase blood flow, not place extremities in the dependent position (off the side of the bed). The nurse will not compress or rub the affected extremities, as this can further damage tissues.
The primary reason for rapid continuous rewarming of the area affected by frostbite is to: a. Lessen the amount of cellular damage b. Prevent the formation of blisters c. Promote movement d. Prevent pain and discomfort
a. Lessen the amount of cellular damage
Mr Rob is caring for a client who experienced a full thickness burn to 65% of the body 12 hrs ago. After establishing a patent airway, which intervention is priority for the client? 1. Replace the clients fluids and electrolytes 2. Prevent the client from developing Curlings ulcers 3. Implement intervention to prevent infection 4. Prepare to assist with an escharotomy
1 (After airway the most urgent need is preventing irreversible shock by replacing Fluids and Electrolytes WRONG: #2 This is important, but not priority over FV. Curlings Ulcer is an acute peptic ulcer of the duodenum resulting as a complication from severe burns when reduced plasma volume leads to sloughing of the gastric mucosa. #3 PRevention of infection is a priority but not prior to maintaining F&E for the first 48-72 hrs. The client will die if F&E is not maintained. #4 An escharotomy, an incision that releases the scar tissue, prevents the body from being able to expand and enables chest excursion in circumferential chest burns. The client has not had time to develop eschar.)
During the emergent (resuscitative ) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? 1 serum creatinine level of 2.5 mg 2. little fluctuation in daily weight 3. hourly urine output 60 mL 4. serum albumin level of 3.8
1 (Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increased serum creatinine. Urine output should be frequently monitored and adequately maintained with IV fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the clients response by monitoring urine output, VS, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to the output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5)
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1.Return of distal pulses 2.Brisk bleeding from the site 3.Decreasing edema formation 4.Formation of granulation tissue
1 Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.
A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? 1. Keep the client on NPO status. 2. Allow the client to have full liquids. 3. Give the client small glasses of clear liquids. 4. Order the client a full meal tray with extra liquids.
1 Rationale: The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst.
A client is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 1. Gastric pH of 3 2.Absence of abdominal discomfort 3. GI drainage that is guaiac negative 4. Presence of hypoactive bowel sounds
1 Rationale: The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor-blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.
There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? SATA 1. an 8 year old with third degree burns over 10% of the body surface area 2. a 20 year old who inhaled the smoke of the fire 3. A 50 year old diabetic with first and second degree burns on the left forearm (about 5% of the body surface area) 4. A 30 year old with second degree burns on the back of the left leg (about 9% of the BSA) 5. A 40 year old with second degree burns on the R arm (about 10% BSA)
1,2,3 (Clients who should be transferred to a burn center include children under the age of 10 or adults over the age of 50 with second- and third- degree burns on 10% or greater of their BSA. Clients between ages 11-49 with second- and third- degree burns of 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA and clients with smoke inhalation, and clients with chronic diseases such as diabetes and heart and kidney disease)
Which nursing interventions should be included for the client who has full thickness burns and deep partial thickness burns to 50% of the body? SATA 1 Perform meticulous hand hygiene 2, Use sterile gloves for wound care 3. Wear gown and mask during procedures 4. Change the central lines once a week 5. Admin antibiotics as prescribed
1,2,3,5 (Yes you use ASEPTIC TECHNIQUE. Central lines ARE NOT CHANGED UNLESS no longer needed or an infection with the line)
Which nursing intervention should be included for the client who has full thickness and deep partial thickness burns to 50% of the body? SATA 1. Perform meticulous hand hygiene 2. Screen visitors for infections 3. Provide low cholesterol,, low protein diet 4. Change invasive lines once a week 5. Administer prophylactic antibiotics as prescribed
1,2,5 (Handwashing is the #1 intervention to prevent infection. The client is at risk for infections and visitors with infections should not be allowed to visit. Prophylactic antibiotics are administered to help prevent infection. WRONG: #3 The client MUST have high protein diet to help with tissue growth. #4 Invasive lines and tubing shoud be changed daily)
A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is admitted to the ED. Which ordered intervention will you implement first? 1. Infuse lactated Ringer's solution at 250 mL/hr. 2. Rinse the back and legs with 4 L of sterile normal saline. 3. Obtain blood for a complete blood count and electrolyte levels. 4. Document the percentage of total body surface area burned.
2 (2 With chemical injuries, it is important to remove the chemical from contact with the skin to prevent ongoing damage. The other actions also should be accomplished rapidly; however, rinsing the chemical off is the priority for this client. Focus: Prioritization)
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: 1. encourage the formation of tough skin 2. promote growth of epithelial tissue 3. provide for permanent wound closure 4. facilitate the development of subcutaneous tissue
2 (Biological dressings such as porcine grafts, serve many purposes for a client with severe burns. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth of subcutaneous tissue)
The male client is admitted to the burn unit after a boiling pot of hot water accidentally spilled on his lower legs. The assessment reveals blistered mottled red skin and both feet are edematous. Which depth burn should George document? 1. Superficial partial thickness 2. Deep partial thickness 3. Full thickness 4. First degree
2 (Deep partial thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin and edema. WRONG: #1 Sunburn is an example of superficial partial thickness burns which affect the epidermis and the skin is reddened and blanches with pressure. #3 Full thickness burns are caused by flame, electrical current, or chemicals, and include the epidermis, entire dermis, and sometimes the subcutaneous tissue, and may also involve connective tissue, muscle and bone. #4 First degree burn is another name for superficial partial-thickness burn)
The rate at which IV fluids are infused is based on the burn clients: 1. lean muscle mass and BSA burned 2. total body weight and BSA burned 3. total BSA and BSA burned 4. height and weight and BSA burned
2 (During the first 24 hrs fluid replacement for the adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight. Total surface area is estimated by taking into account the individuals height and weight. Height is not a common variable used in formulas for fluid replacement)
Ms Glada is developing a nursing care plan for a client who experienced full thickness burn and deep partial-thickness burns over half the body 4 days ago Which client problem should Ms. Glada make priority? 1. High risk for infection 2. Pain 3. Impaired physical mobility 4. Fluid and electrolyte balance
2 (Pain is the clients priority problem. The client has full thickness burn, which has no pain, but the DEEP partial thickness burns are VERY painful. WRONG: #1 This is a pertinent problem because the protective barrier has been compromised and there is impaired immune response, but not priority over pain #3 Burn wound edema, pain, and potential joint contractures can cause mobility deficit, but not before infection which follows pain. #4 AFTER 48-72 hrs F&E is no longer the priority. This client is 4 DAYS POST initial burn)
The client admitted to the ED with a third-degree burn over the front of both legs. Which priority intervention should the nurse implement? 1. maintain a sterile environment when caring for the client 2. Insert two large-bore IV access routes 3. Admin IV antibiotic therapy 4. Assess the clients pain level on a 1-10 scale
2 (The priority intervention in the first 24 hrs is for the client with third degree burn is maintaining intravascular volume so the client will not die from hypovolemic shock. WRONG: #1 The environment should be maintained, but priority is fluid volume. #3 infection prevention is important, but FV is priority. #4 Pain should be assessed but for a client with 3rd degree burns over both legs fluid volume is priority)
A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? 1.Superficial 2.Full-thickness 3.Deep partial-thickness 4.Partial-thickness superficial
2 Rationale: Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.
A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse should anticipate observing which sign/symptom? 1. Coma 2. Flushing 3.Dizziness 4. Tachycardia
2 Rationale: The signs and symptoms worsen as the carbon monoxide level rises in the bloodstream. Impaired visual acuity occurs at 5% to 10%, whereas flushing and headache are seen at 11% to 20%. Nausea and impaired dexterity appear at levels of 21% to 30%, and a 31% to 40% level is accompanied by vomiting, dizziness, and syncope. Levels of 41% to 50% cause tachypnea and tachycardia, and those higher than 50% result in coma and death.
A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.
2,3,5 Rationale: The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock. The client is kept warm and placed on NPO status because of the altered gastrointestinal function that occurs as a result of a burn injury.
The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? 1. Pain level 2. Lung sounds 3. Ability to swallow 4. Laboratory results
2Rationale: The priority nursing action would be to assess lung sounds. Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and cause erythema and edema of the airways and mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after burn injury.
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm from hand to just below shoulder, and right leg from thigh to toes. Using the "rule of nines" estimate what percentage of the clients BSA has been burned? 1 18% 2 27 % 3 45% 4. 64%
3 (According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9% The right leg is 18% and the anterior trunk is 18% for a total of 45%)
The nurse is caring for a client with severe burns who is receiving fluid resuscitation, Which finding indicates that the client is responding to the fluid resuscitation? 1. pulse rate of 112 bpm 2. BP of 94/64 3. urine output of 30 mL/hr 4 serum sodium level of 136
3 (Ensuring a urine output of 30-50 ml/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The BP is low, likely related to hypovolemia, but the urinary output is he more accurate indicator of fluid balance and kidney function. The Na is wnl)
The nurse is applying mafenide acetate (Sulfamylon) a sulfa antibiotic cream, to a clients LE burn. Which assessment data would require immediate intervention by the nurse? 1. The client complains of pain when the med is administered 2. The clients potassium level is 3.9 and Na is 137 3. The Clients ABGs are Ph 7.34, PaO2 98, PaCo2 38, and HCO3 20 4 The client is able to perform active ROM exercises
3 (Sulfamylon is a STRONG carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immed intervention.)
A client is receiving fluid replacement with lactated Ringers after 40% of the body was burned 10 hrs ago. The assessment reveals temperature 97.1 (36.2 C) HR 122, BP 84/42, central venous pressure (CVP) 2 and urine output 25 mL/hr for the last 2 hours Using the SBAR technique for communication, the nurse calls the HCP with recommendation for: 1. furosemide 2, fresh frozen plasma 3. IV rate increase 4. dextrose 5%
3 (The decrease urine output, low BP, low CVP, and a high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given with FVD. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is LR, NS or albumin.)
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse. "What is a xenograft?" Which statement by the nurse is the best response? 1. The doctor will graft skin from your back to your leg 2. The skin from a donor will be used to cover your burn 3. The graft will come from an animal, probably a pig 4. I think you should ask your Dr about the graft
3 (a xenograft or heterograft consists of skin taken from animals usually porcine. WRONG: #1 This is an autograft, #2 This is a homograft. #4 This is passing the buck)
An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1.18% 2.24% 3. 36% 4. 48%
3 Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.
A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition? 1. Pain 2. Fear 3. Hypoxia 4. Anxiety
3 Rationale: After a burn injury, clients normally are alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and also may occur after an electrical injury. Although anxiety, fear, and pain may occur, confusion and combativeness are most likely associated with hypoxia.
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains dextrose in water
3 Rationale: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore the HCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. Blood replacement is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because it would not replace needed fluid. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Dextrose in water is an isotonic solution, and an isotonic solution maintains fluid balance. This type of solution may be administered after the first 24 hours following the burn injury, depending on the client's physiological needs.
The nurse is conducting a focused assessment of the GI system of a client with a burn injury. The nurse should assess the client for : 1. paralytic ileus 2. gastric distension 3. hiatal hernia 4. Curlings ulcer
4 (Curlings Ulcer or GI ulceration occurs in about half of clients with a burn injury. The incidence of ulceration appears proportionate to the extent of burns, and the ulceration is believed to be caused by hypersecretion of gastric acid and compromised GI perfusion. PAralytic ileus. and gastric distension do not result from hypersecretion of gastric acid and stress and thus are not expected at this time. Hiatal hernia is not necessarily a potential complication of a burn injury)
During the early phase of burn care, the nurse should assess the client for: 1. hypernatremia 2. hyponatremia 3. metabolic alkalosis 4. hyperkalemia
4 (Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as the result of loss of sodium bicarb HCO3)
The client with an electrical burn is brought to the ED The entrance wound is on the R hand and the exit wound is on the L foot. Which intervention should the nurse implement first? 1. Place sterile gauze on the entrance and exit wounds 2. Assess the clients VS 3. Monitor the pulse oximetery 4. Place the client on cardiac telemetry
4 (The electrical current in the body bounces off bone and goes through muscle. The heart is a muscle; therefore the priority intervention is for the nurse to apply cardiac monitors to assess for lethal dysrhythmias that may occur. WRONG: #1 The wounds need to be kept sterile to decrease the chance of infection, but not priority #2 The clients need VS assessed, but priority with electrical is cardiac monitoring #3 The clients o2 should be monitored but not priority with electrical /cardiac)
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula at 6 L/minute 3. Oxygen via nasal cannula at 15 L/minute 4. 100% oxygen via a tight-fitting, nonrebreather face mask
4 Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Options 1, 2, and 3 are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion.
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1.Decreased heart rate 2.Increased urinary output 3.Increased blood pressure 4.Elevated hematocrit levels
4 Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.
A client is diagnosed with a full-thickness burn. The nurse plans care, knowing that which structural areas of the skin are involved? 1.Epidermis only 2.Epidermis and deeper dermis 3.Epidermis and upper layer of dermis 4.Epidermis, entire dermis, and epithelial portion of subcutaneous fat
4. Rationale: A full-thickness burn involves the epidermis, entire dermis, and epithelial portion of subcutaneous fat layer. Options 1, 2, and 3 describe superficial, moderate partial-thickness, and deep partial-thickness burns, respectively.
A nurse provides care for a client with Sjögren syndrome. Which interventions does the nurse include in the plan of care? SATA A. Assessment of the oral mucosa B. Administration of corticosteroids C. Administration of anticholinergics D. Administration of artificial tears E. Offering frequent drinks
A, B, D, E Sjögren syndrome is a chronic, systemic autoimmune disease that affects exocrine glands. It causes a deficiency in saliva, tears, skin lubrication, and other exocrine secretions. Clients may also experience fatigue, musculoskeletal symptoms, rashes, and internal organ diseases. Sjögren syndrome may occur on its own or be associated with other autoimmune disorders. Treatment involves symptom relief and prevention of eye damage and periodontal disease.
The nurse identifies which statements about Stevens-Johnson syndrome as true? (Select all that apply.) A) Patients with Stevens-Johnson syndrome have a mortality rate of about 25%. B) Toxemia is associated with Stevens-Johnson syndrome. C) Short-acting sulfonamides do not induce Stevens-Johnson syndrome. D) Patients with Stevens-Johnson syndrome usually are hypothermic. E) Lesions of the mucous membranes are a characteristic of Stevens-Johnson syndrome.
A,B,E Short-acting sulfonamides do induce Stevens-Johnson syndrome on rare occasions, and patients with Stevens-Johnson syndrome usually are hyperthermic. The other three statements are true.
A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Hide under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove all body piercings. f. Put down golf clubs or gardening tools.
A,C,D,F When thunder is heard, shelter should be sought in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person's chances of being struck by lightning.
After teaching a patient diagnosed with progressive systemic sclerosis about health maintenance activities, the nurse determines that additional instruction is needed when the patient says, a. "I should lie down for an hour after meals." b. "Paraffin baths can be used to help my hands." c. "Lotions will help if I rub them in for a long time." d. "I should perform range-of-motion exercises daily."
ANS: A Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective.
Which statement by a 24-year-old woman with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse's teaching about management of the condition? a. "I will use a sunscreen whenever I am outside." b. "I will try to keep exercising even if I am tired." c. "I should take birth control pills to keep from getting pregnant." d. "I should not take aspirin or nonsteroidal anti-inflammatory drugs."
ANS: A Severe skin reactions can occur in patients with SLE who are exposed to the sum. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal anti-inflammatory drugs are used to treat the musculoskeletal manifestations of SLE.
A patient has systemic sclerosis manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep patient's room warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.
ANS: B Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose levels or to assist the patient to the bathroom every 2 hours.
The health care provider has prescribed the following collaborative interventions for a 49-year-old who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Use naproxen (Aleve) 200 mg BID. d. Take famotidine (Pepcid) 20 mg daily.
ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.
The nurse obtains this information when assessing a patient who is taking hydroxychloroquine (Plaquenil) to treat SLE. Which symptom is most important to report to the health care provider? a. Abdominal cramping b. Complaint of blurry vision c. Phalangeal joint tenderness d. Blood pressure 170/84 mm Hg
ANS: B Plaquenil can cause retinopathy; the medication should be stopped. The other findings are not related to the medication, although they also will be reported.
When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep
ANS: B The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.
The nurse is assessing a client with Paget's disease. Which assessment finding leads the nurse to notify the health care provider immediately? a. Client is 5 feet in height and weighs 130 pounds. b. Long bones of the legs and arms are bowing. c. Base of the skull is enlarged with changes in vital signs. d. Mild pain is present in the area of the hips and pelvis.
ANS: C It is common for the client with Paget's disease to be short in stature and to develop bowing of the long bones and mild to moderate pain, which often occurs in weight-bearing joints. When the skull becomes enlarged with basilar invagination, the brainstem may become damaged; this can threaten the vital sign center and life itself.
When preparing to care for a client with a family history of Paget's disease, it is most important for the nurse to include education in which area? a. Avoidance of infections b. Exercise program c. Nutrition high in vitamin C d. Need for genetic testing
ANS: D Paget's disease has been noted in up to 30% of people with a positive family history. Clients who have a history of this disease in their family should be taught the importance of genetic counseling. An exercise program may be started with the help of a physical therapist, but exercise may be difficult because of pain and danger of fracture. The diet should be rich in calcium and vitamin D.
A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include? A. "Using arm splints will prevent hyperflexion of the wrist." B. "This condition is associated with various sports." C. "Ergonomic changes can be incorporated into your workday to reduce stress on your wrist." D. "Surgery is the only sure way to manage this condition."
C. Ergonomic changes can be incorporated into your workday to reduce stress on your wrist." Explanation: Ergonomic changes, such as adjusting keyboard height, can help clients with carpal tunnel syndrome avoid hyperextension of the wrist. This condition is associated with repetitive tasks such as clerical work, not sports. The condition may be managed with medications, yoga, acupuncture, and wrist (not arm) splints.
A nurse is providing teaching for a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. "I should use a suncreen with an SPF of at least 15" B. "Long-term immunosuppresive therapy could cure this disease" C. " I should wear gloves when it is cold outside" D. "SLE should not affect my lungs or breathing"
C. raynaud's syndrome commonly accompanies SLE and can cause painful vasoconstriction in the fingers when they are exposed to cols temps
A 25 year old male is at the ED with a rattlesnake bite. He was removing shrubs when he placed his hand into a thick area of brush and felt something bite him. Friends captured a picture of the snake and showed the ED staff so that the patient would receive the correct antivenom. As a nurse administers CroFab, the antivenom, the client ask how long he will need to receive the medication. How should the nurse respond? A. "I will be giving you this medication for at least 36 hours" B. "The medication is usually given over a 4-day time period" C."You will be given this antivenom over a period of 18 hours" D. "You will have to take this medication for the rest of your life"
C."You will be given this antivenom over a period of 18 hours"
A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is MOST important to emphasize to an older adult in dealing with the effects of the sunburn? 1. increasing fluid intake 2. applying mild lotions 3. taking mild analgesics 4. maintaining warmth 5. using sunscreen
Correct Answer: 1 Rationale: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important. Other manifestations could include nausea and vomiting. All the measures help alleviate the manifestations of this minor burn which include pain, skin redness, chills, and headache. Use of sunscreen is a preventative, not a treatment measure.
The nurse notes that a patient with third-degree burns is demonstrating a reduction in his serum potassium level. The nurse realizes that this finding is consistent with which of the following? 1. the resolution of burn shock 2. the onset of burn shock 3. the onset of renal failure 4. the onset of liver failure
Correct Answer: 1 Rationale: Potassium levels are initially elevated during burn shock but will decrease after burn shock resolves as fluid shifts back to intracellular and intravascular compartments. Reduced potassium levels are not indicators of the onset of renal or liver failure.
Following surgical debridement, a patient with third-degree burns does not bleed. The nurse realizes that this patient 1. will need to have the procedure repeated. 2. will no longer need this procedure. 3. will need to be premedicated prior to the next procedure. 4. should have an escharotomy instead.
Correct Answer: 1 Rationale: Surgical debridement is the process of excising the burn wound by removing thin slices of the wound to the level of viable tissue. If bleeding does not occur after the procedure, it will be repeated. It is an assumption that patients having debridement will all require premedication. An escharotomy involves removal of the hardened crust covering the burned area.
When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the findings? 1. These values are normal for the patient's post-burn injury condition. 2. The patient is demonstrating manifestations consistent with the onset of an infection. 3. The patient is demonstrating manifestations consistent with an electrolyte imbalance. 4. The patient is demonstrating manifestations consistent with renal failure. 5. The patient is demonstrating manifestations of fluid volume overload.
Correct Answer: 1 Rationale: The burn-injured patient is not considered tachycardic until the heart rate reaches 120 beats per minute. In the absence of other symptoms, the temperature does not signal the presence of an infection. It could be a response to a hypermetabolic response.
A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer, who is a nurse, runs to the victim's aid. What does the nurse do initially? a. Applies a dressing over the skin burn where the lightening entered b. Instructs everyone to not touch the victim to avoid being hurt c. Moves the victim to a more secure area d. Palpates to check for the presence of a pulse
D (The most lethal initial effect of the massive current discharge of lightning on the cardiopulmonary system is asystole. The nurse needs to palpate for a pulse and begin cardiopulmonary resuscitation (CPR), if necessary.)
A patient diagnosed with carpal tunnel syndrome (CTS) asks the nurse about numbness in the fingers and pain in the wrist. In responding to the patient, how would the nurse best describe CTS? A. "CTS is a neuropathy that is characterized by pannus formation in the shoulder." B. "CTS is a neuropathy that is characterized by flexion contracture of the fourth and fifth fingers." C. "CTS is a neuropathy that is characterized by bursitis and tendinitis." "D. CTS is a neuropathy that is characterized by compression of the median nerve at the wrist."
D. "CTS is a neuropathy that is characterized by compression of the median nerve at the wrist."
A 40-yr-old African American woman has longstanding Raynaud's phenomenon. Currently, she reports red spots on her hands, forearms, palms, face, and lips. Which additional findings will the nurse expect (select all that apply)? a. Calcinosis b. Weight loss c. Sclerodactyly d. Difficulty swallowing e. Weakened leg muscles f. Skin thickening below the elbow and knee
a. Calcinosis c. Sclerodactyly d. Difficulty swallowing f. Skin thickening below the elbow and knee This patient is at risk for scleroderma. The acronym CREST represents the clinical manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.
Which nursing intervention would be most appropriate for a patient with Sjögren's syndrome? a. Ambulate with assistive devices b. Use lubricating eye drops frequently c. Administer acetaminophen as needed d. Apply ice or heat compresses to affected areas
b. Use lubricating eye drops frequently Sjögren's syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.