exam 1 practice

a 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. using the rule of nines calculate the total burn surface area percentage that is burned

37

a 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk, using the rule of nines calculate the total body surface area percentage that is burned

58.5

a 66 year old female patient has deep partial thickness burns of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. using the rule of nines calculate the total body surface area percentage burned

81%

a home care nurse is performing a visit to a clients home to perform wound care following the clients hospital treatment for severe burns while interacting with the client the nurse should assess for evidence of what complication

PTSD

a nurse is planning the care of a client with herpes zoster what medication if given within the first 24 huors of the initial eruption can arrest herpes zoster

acyclovir

the nurse is preparing to administer a unit of platelets to an adult client when administering this blood product which of the following actions should the nurse perform

administer the platelets as rapidly as the client can tolerate

sensitivity reaction to a plasma protein within the blood component

allergic reaction

a client has experienced burns to his upper thighs and knees following the application of new wound dressings the nurse should perform what nursing action

assess the clients peripheral pulses distal to the dressing elevate burned extremities

a clients low hemoglobin level has necessitated transfusions of PRBCs. prior to administration what action should the nurse perform

assess the clients vital signs to establish baselines written consent type and cross match blood

a nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis what assessment should the nurse prioritize in this clients plan of care

assessment for variceal bleeding

a nurse is caring for a client with hepatic encephalopathy. while making the initial shift assessment the nurse notes that the client has a flapping tremor of the hands. the nurse should document the presence of which of the liver disese

asterixis

the nurse is providing health promotion education to a client diagnosed with an esophageal reflux disorder what practice should the nurse encourage the client to implement

avoid carbonated drinks keep HOB elevated avoid caffeinated drinks

an interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions what action has the greatest potential to reduce the risk of this transfusion reaction

be vigilant in identifying the client and the blood component

an unresponsive caucasian client has been brought to the Er by EMS. while assessing this client the nurse notes that the clients face is a cherry red color, what should the nurse suspect

carbon monoxide posining

a client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. the nurse should monitor closely for what signs of the onset of burn shock

decreased bp

a client newly diagnosed with thrombocytopenia is admitted to the medical unit after the admission assessment the client asks the nurse to explain the disease what potential etiology should the nurse explain to this client

decreased production of platelets

burn that involves the epidermis, upper dermis, and portion fo the deeper dermis

deep partial thickness

a nurse is caring for a client who has burns to his face, ears, and eyelids the nurse should identify which of the following is the priority finding to report to the provider

difficulty swallowing

a client is recieving the first of two prescribed units of PRBCs. shortly after the intiation of the transfusion the client reports chills and experiences a sharp increase in temp, what is the nurses priority action

discontinue transfusion

a group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. what action has the greatest potential to reduce a nurses risk of acquiring hepatitis C in the workplace

disposing of sharps appropriately and not recapping needles

how to take iron

empty stomach with vitamin C eat foods high in fiber to help with constipation

a nurse is caring for a client who just has been diagnosed with a peptic ulcer when teaching the client about his new diagnosis how should the nurse best describe it

erosion of the lining of the stomach or intestine

the most common cause of acute hemolytic reactions are

errors in blood component labeling and client identification of an ABO incompatibility transfusion

antibodies to donor leukocytes remain int he unit of blood or blood component

febrile reaction

a client has been admitted to a burn intensive care unit with extensive full thickness burns over 25% of the body after ensuring cardiopulmonary stability what would be the nurses immediate priority concern when planning this clients care

fluid status

during a health education session a participant has asked about the hep E virus what prevention measure should the nurse recommend for preventing infection with this virus

following proper hand washing techniques transmitted fecal oral route

a nurse is assisting with serving dinner trays on the unit upon recieving the dinner tray for a client admitted with acute gallbladder inflammation the nurse will question which of the following foods on the tray

fried chicken should be low fat liquids avoid fatty fried foods

a client is brought to the ER from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. on inspection the skin appears charred based on these assessment findings what is the depth of the burn on the client arm

full thickness

total destruction of the epidermis and dermis

full thickness

a client comes to the clinic reporting red rash of small fluid filled blistersand is suspected of having herpes zoster what presentation is most consistent with this diagnosis

grouped vesicles in linear patches along a dermatome

a nurse has entered the room of a client with cirrhosis and found the client on the floor. the client states that she fell when transferring to the commode, the clients vital signs are within reference ranges and the nurse observes no appraent injuries. what is the nurses most appropriate action

have the client assess by the primary provider due to the risk of internal bleeding

the nurse is describing normal RBC physiology to a client who has a diagnosis of anemia. the nurse should explain that the RBCs consist primarily of which of the following

hemoglobin

a clients assessment and diagnostic testing are suggestive of acute pancreatitis when the nurse is performing the health interview what assessment questions address likely etiology factors? SATA

how many alcoholic drinks do you typically consume in a week have you ever been diagnosed with gallstones

a client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn upon analysis of the clients lab studies the nurse will expect the results to indicate what

hyperkalemia, hyponatremia, and elevated hematocrit

a nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hep b what preventative measures should the educator promote SATA

immunization use of standard precaution

a client is receiving care in the ICU for acute pancreatitis the nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. consequently the nurse should assess for what signs and symptoms of this complication

increased abdominal girth accompanied by decreased level of consciousness

a clients abdominal ultrasound indicates cholelithiasis when the nurse is reviewing the clients lab studies what finding is most closely associated with this diagnosis

increased bilirubin

a client seeking care bc of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. which of the following should the nurse include in health education

instead of eating three meals a day try eating smaller amounts more often

a client has come to the OBGYn clinic due to recent heavy menstraul flow. bc of the clients consequent increase in red cell production the nurse should recommend the client increase her daily intake of what substance

iron

a nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. what should the nurse include in health education

iron will cause the stools to darken in color

results of a client bariums swallow suggest that the client has GERD the nurse is planning health education to address the clients knowledge of this new diagnosis. which of the following should the nurse encourage

keeping the head of bed partially elevated no carbonated beverages no eating or drinking 2 hours before bed

a nurse is monitoring the fluid replacement of a client who has sustained burns the nurse should administer which of the following fluids in the first 24 hours following a burn injury

lactated ringers

a clients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the ER. after establishing IV access the nurse should anticipate the administration of what fluid

lactated ringers not normal saline

a staff educator is reviewing the causes of GERD with new staff nurses what area of the Gi tract should the educator identify as the cause of reduced pressure associated with GERD

lower esophageal sphincter

a client comes to the clinic reporting pain in the epigastric region. what statement by the client suggests the presence of a duodenal ulcer

my pain resolves when i have something to eat

a nurse is caring for a client who has a diagnosis fo GI bleed. during shift assessment the nurse finds the client to be tachycardiac and hypotensive and the client has an episode of hematemesis while the nurse is in the room. in addition to monitoring the vital signs and level of conscious what would be a priority nursing action for this client

notfy the health care provider

what disease gets triamicnolone

psoriasis

a nurse is caring for a client with cirrhosis secondary to heavy alcohol use the nurses most recent assessment reveals subtle changes in the clients cognition and behavior what is the nurses most appropriate response

report finding to the primary provider due to the possibility of hepatic encephalopathy

an older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency in addition to a complete blood count what diagnostic assessment should the nurse anticipate

stool for occult blood

a nurse is caring for a client who has peptic ulcer disease the nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation

sudden abdominal pain decreased bowel sounds and paralytic ileus decrease BP, tachycardia hypovolemic shock

burn that involves the epidermis and possibly a portion of the dermis

superficial partial thickness

a client with a history of peptic ulcer disease has presented to the ER in distress. what assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer

the client has a rigid boardlike abdomen that is tender

which of the following circumstances would most clearly warrant autologous blood donation

the client has elective surgery pending

a nurse on the burn unit is caring for a client who experiences burn injuries 2 days ago. the client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. how should the cleints change in status be best udnerstood

the client is likely experiencing a delayed onset of resp complications

a client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction what was the etiology of this clients adverse reaction

the donor blood was incompatible with that of the client

a client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit how should the nurse most likely explain the pathophysiology of this clients health problem

the enzymes that your pancreas produce have damaged the pancreas itself

an ER nurse has just admitted a client with a burn what characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury

the total body surface area affected by the burn

a client with a diagnosis of peptic ulcer disease has just been prescribed omeprazole how should the nurse best describe this medications therapeutic action

this medication will reduce the amount of acid secreted in your stomach