Exam 4

A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? Select all that apply.

burn odor leathery skin cardiac arrest

A client who had an organ transplant is receiving cyclosporine. The nurse should monitor for what serious adverse effect of cyclosporine?

Increased creatinine level

A client with jaundice associated with hepatitis expresses concern over the change in skin color. What does the nurse explain is the cause of this color change?

Inability of the liver to remove normal amounts of bilirubin from the blood

The nurse is providing discharge instructions to a client who is recovering from an acute case of viral hepatitis. Which statement by the client indicates a need for further education?

"I will take acetaminophen for pain rather than aspirin."

An adolescent girl who has sustained superficial partial-thickness burns of the face because of excessive exposure to the sun exclaims, "Prom night is only 4 weeks away. I'll never be healed!" What is the nurse's best response?

"Recovery will take about 3 weeks."

What would be the priority nursing intervention in a client with electric burns?

ABC

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas?

Ammonia level

A client who had a kidney transplant develops leukopenia 3 weeks after surgery. What does the nurse conclude is the most probable cause of the leukopenia?

Antirejection medications

A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply.

Ascites Pruritus Jaundice

Which wound care is given to a client with severe burn injuries during the acute phase?

Assess the wound daily and adjust the dressing

A severely burned client has been hospitalized for 3 days and is now in the acute phase. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. What does the nurse conclude the client is most likely developing?

Cerebral hypoxia

A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom?

Clay-colored stools

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure the nurse can instruct the person to apply before seeking healthcare?

Cool, moist towels

A nurse is caring for a client with end-stage kidney disease after a kidney transplant. Which finding indicates the transplant is successful?

Decreasing serum creatinine

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which classification should the nurse use to describe these burns?

Deep partial-thickness

On the second day after sustaining extensive severe burns a 6-year-old child exhibits edema and decreased urine output. For which additional adverse response should the nurse assess the child in this early stage of burn injury?

Disorientation

A nurse teaches the signs of organ rejection to a client who had a kidney transplant. What should the nurse include in the education?

Elevated blood pressure

A client is diagnosed as having the hepatitis B virus (HBV). The nurse reviews the client's health history for possible situations in which exposure may have occurred. Which event does the nurse determine is most likely the source of this infection?

Had a small tattoo on the arm three months ago

A nurse needs to administer fluid in a severely burned child of 2 years, but the peripheral vein is obscured. Which other route should the nurse use?

Intraosseous

The nurse is caring for a client with deep partial-thickness burns who is receiving an opioid for pain management. What is the preferred mode of medication administration for this client?

Intravenous

Which key feature would the nurse explain indicates malignancy in an acute immunodeficiency syndrome (AIDS) client?

Kaposi sarcoma

A client with a history of cirrhosis of the liver develops heart failure. When ventricular bigeminy develops, the provider orders lidocaine. What alterations in lidocaine dosages does the nurse anticipate?

Lower because the drug is metabolized at a diminished rate

A client has end-stage kidney disease and is admitted for a kidney transplant. Which information should the nurse share when teaching about the donor?

Must have matching leukocyte antigen complexes

A client is brought to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. To assess for heat inhalation, the nurse first should observe for which finding?

Nasal discharge containing carbon particles

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority?

Observe the client for increasing confusion

What will the nurse do to assess a client's response to ongoing serum albumin therapy for cirrhosis of the liver?

Obtain the client's weight at least once every day

Which complication may be caused by sepsis in burns?

Paralytic ileus

A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication?

Place the medication directly on the burn wound in a thin layer using sterile gloves.

The disaster management team is caring for workers of a factory who survived a thermal blast. Which findings in the workers would the nurse consider as confirmation of second degree burns?

Presence of moist blebs and skin appears mottled white or pink

A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. What should the nurse assess for in this client?

Prolonged wound healing

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum?

Sooty

A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. What is the nurse's priority intervention?

Starting an intravenous line with a large-bore catheter

A client has a tentative diagnosis of primary biliary cirrhosis. What skin change does the nurse expect to observe when performing a physical assessment?

Telangiectasia

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication?

60 minutes before the dressing change

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what?

Urinary output

A client with cirrhosis is scheduled for a liver biopsy. The client asks if there are any risks after the procedure. Which response by the nurse is the best?

"The major risk is bleeding postprocedure."

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?

Crackles in the lungs

A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority?

Institute fall prevention/safety measures.

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. Which response by the nurse is most appropriate?

epidermis

A client has a kidney transplant. The nurse should monitor for which assessment findings associated with rejection of the transplant? Select all that apply.

fever oliguria weight gain

A client has been diagnosed as brain dead. The nurse understands that this means that the client has what?

No cortical functioning with some reflex breathing

A 6-year-old child has partial-thickness burns of the face and upper chest. What is the prioritynursing assessment for the first 24 hours?

Pulmonary distress

A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply.

Brassy cough Singed nasal hair Dark mucous membranes

A preschooler with partial-thickness burns on 21% of the total body surface area progresses from the emergency phase to the acute phase of burn care. What is the most important nursing intervention at this time?

Instituting a pain management plan

A healthcare provider prescribes oral aluminum-magnesium hydroxide and intravenous ranitidine for a client with traumatic burns and crush injuries. The client asks how these medications work. What is the nurse's best response?

"They limit acidity in the gastrointestinal tract."

A school nurse is teaching a health class of 12-year-olds about hepatitis C. Which statement by a student indicates an understanding of the origin of the disease?

"You can catch it while you're getting a tattoo.

A client is waiting for a kidney transplant. What explanation should the nurse include when teaching the client about the transplant?

"You will require immunosuppressive drugs daily for the rest of your life."

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse should give priority to which client history item?

Black, tarry stools

A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. What is the nurse's best reply?

"All family members, including your child, need to wash their hands after using the bathroom."

In the immediate period after admission to the burn unit with severe burns, a 5-year-old child requests a drink of milk. What is the most appropriate nursing intervention?

Maintaining NPO status for 24 to 48 hours

The nurse is providing postoperative care to a kidney transplant recipient. What is the nurse's first priority during this period?

Maintaining fluid and electrolyte balance

A school-aged child is admitted to the hospital with severe burns on the arms. Therapeutic escharotomy is planned. What is the prioritynursing action at this time?

Monitoring radial pulses

A client is at high risk for developing ascites because of cirrhosis of the liver. How should the nurse assess for the presence of ascites?

Percuss the client's abdomen and listen for dull sounds.

Following a fire, the disaster management team assesses burn injuries of the survivors. The team finds that most survivors have pink to cherry red skin with blisters. Which type of burns does the nurse identify on the survivors?

Second degree burns

A nurse is caring for a client who had a kidney transplant. Which test is most important for the nurse to monitor to determine whether a client's newly transplanted kidney is working effectively?

Serum creatinine

The primary healthcare provider prescribes medication to prevent transplant rejection from increased concentration of interleukin-2. Which drugs could the nurse most likely administer? Select all that apply.

Tacrolimus and cyclosporine

A client on medication for transplant rejection is admitted with hypertension, nephrotoxicity, and gingival hyperplasia. Which medication might have caused this? Select all that apply.

Tacrolimus and cyclosporine are calcineurin inhibitors that may cause adverse effects such as hypertension, nephrotoxicity, and gingival hyperplasia.

When preparing discharge teaching for a client who had a kidney transplant, in addition to a corticosteroid, the nurse expects what other medications to be prescribed to prevent kidney rejection?

Tacrolimus and mycophenolate mofetil

A nurse is developing a discharge plan for a client hospitalized with severe cirrhosis of the liver. What should be included in this plan?

The importance of reporting personality changes to the primary healthcare provider

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics?

Topical

A 6-year-old child who was rescued from a burning building is admitted to the burn unit with a diagnosis of smoke inhalation. For which prioritycomplication should the nurse assess the child?

Tracheobronchial edema

An adult client with mobility problems wishes to become an organ donor. Which act allows the client to donate his or her organs?

Uniform Anatomical Gift Act

A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. For which condition is it most important for the nurse to assess this client?

Blood in the stool

The nurse is assessing a client with severe cirrhosis and discovers fetor hepaticus. What did the nurse assess?

Breath

A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment?

Moderate protein

A client with biliary cirrhosis receives serum albumin therapy. What is the most effective method for the nurse to evaluate the client's response to therapy?

Weight daily

A client is diagnosed with hepatitis A. The nurse takes the client's history. Which employment history is most likely linked to the development of hepatitis A?

Works at a plumbing business

A client recovering from hepatitis A asks the nurse about returning to work. Which is the best response by the nurse?

"Gradually increase your activities because relapses may occur in those who return to full activity too soon."

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the mostsignificant data?

Urinary output every hour

A nurse is caring for a client with end-stage kidney disease who is about to receive a transplant. When the client returns from the postanesthesia care unit after a kidney transplant, how often should the nurse measure the client's urinary output?

1 hour

What is an example of third spacing in a burn injury?

Blister formation

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall?

Partial-thickness burns are often painful, reddened, and have blisters.

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder?

Penne pasta, spinach, banana, and decaffeinated iced tea

A client with Laënnec cirrhosis has ascites and jaundice and is confused. What is the nursing priority when caring for this client?

Providing for the client's physical safety

The emergency department nurse is assigned to care for a family of four clients who present with carbon monoxide poisoning. Which client should be given the top priority of care?

client with cardiopulmonary instability

Which type of burn/injury may cause a client to have a cervical spine injury?

electrical

A 3-year-old child is admitted with partial- and full-thickness burns over 30% of the body. What significant adverse outcome during the first 48 hours should the nurse attempt to prevent?

shock

Which gastrointestinal (GI) change may be found in the client with burn injuries?

Abdominal distention

A nurse is caring for a client who recently had a kidney transplant. Which priority assessment finding requires follow up by the nurse?

Fever

The nurse is caring for a client who is receiving azathioprine, cyclosporine, and prednisone before receiving a kidney transplant. What does the nurse identify as the purpose of these drugs?

Reduce antibody production

A client who experiences anorexia and fatigue develops jaundice. A diagnosis of hepatitis A is made. The client's spouse and adult children who still live at home ask whether they should receive gamma globulin. Which is the mostappropriate response by the nurse?

"You should call your primary health care provider immediately about getting gamma globulin."

A nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information should the nurse include in the teaching session? Select all that apply.

Avoiding aspirin and aspirin-containing products Avoiding acetaminophen and products containing acetaminophen Avoiding coughing, sneezing, and straining to have a bowel movement

A nurse is assessing a malnourished client with a history of cirrhosis. The client is experiencing nausea, ascites, and gastrointestinal bleeding. What is the primary cause of the client's ascites?

A decrease in plasma protein to maintain adequate capillary-tissue circulation

The nursing instructor determines that the student nurse understands the type(s) of hepatitis that mostcommonly are spread by consuming contaminated food and water or by fecal contamination if the student identifies which of these diseases? Select all that apply.

Hepatitis A and E

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for?

Hyperkalemia

A client with 35% of total body surface area burned in a fire is now 48 hours postburn. The nurse concludes that the client is moving from the emergent to the acute phase of burn management. Which finding supports the nurse's conclusion?

Hypokalemia

A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likelycause of this client's ascites?

Impaired portal venous return

A nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. What does the nurse conclude is the probable cause of ascites?

Impaired portal venous return

While the nurse was caring for a client with chemical burns after a factory explosion, there was increased edema in the surrounding tissues. What might have led to increased edema?

Lowering burned limbs below the heart

A nurse is caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the priority during the emergent phase of a burn injury?

Managing fluid loss

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply.

Providing oxygen immediately Notifying the rapid response team

A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which of these conditions results from this imbalance?

Reduction of colloidal osmotic pressure in the blood

A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. What should the nurse instruct the client to do considering the client's condition?

Report signs of bleeding no matter how slight.

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase?

Restoring fluid volume

A nurse is teaching a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions should be included in this teaching plan? Select all that apply.

Screening of blood donors Maintaining a monogamous sexual relationship

A client who has been receiving hemodialysis for several years is to receive a kidney transplant. What should the nurse share in the client's preoperative teaching plan? Select all that apply.

"The kidney may not function immediately." "Precautions are needed to prevent infection" "A urinary catheter will be present postoperatively."

A client who has been receiving hemodialysis for several years is to receive a kidney transplant. What should the nurse share in the client's preoperative teaching plan? Select all that apply.

"The kidney may not function immediately." "Precautions are needed to prevent infection." "A urinary catheter will be present postoperatively.

A client with hepatitis B asks the nurse, "Are there any medications to help me get rid of this problem?" Which is the best response by the nurse?

"There are medications to help reduce viral load and liver inflammation."

A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. What is the nurse's best response?

"They aid absorption of fat-soluble vitamins."

A client is admitted with 50% of the body surface area burned after an industrial explosion and fire. The client's serum albumin is 1.5 g/dL (150 mg/dL), the hematocrit is 30%, the urine specific gravity is 1.025, and the serum globulin is 3 g/dL (300 mg/dL). When evaluating the client's response to fluid replacement, what determines when the nurse should prepare to administer a colloid?

Albumin is below 2 g/dL (200 mg/dL)

The nurse is providing induction therapy to a client to prevent rejection after an organ transplant. Which medication will the nurse most likely administer?

Atgam

A 10-year-old child who was rescued from a house fire is brought to the emergency department with burns of the extremities. During assessment of the child, what finding is of mostconcern to the nurse?

Burns around the mouth

Which type of hepatitis virus spreads through contaminated food and water?

Hepatitis A virus

Neomycin is prescribed for a client with cirrhosis. What should the nurse explain is the reason for taking this medication?

Reduces the blood ammonia level

A client with Laënnec cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. What is the nursing priority?

Implement fall precautions/prevention measures

A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. Which process that most likely caused the ascites should the nurse consider when planning care?

Increased pressure in the portal vein

A nurse is caring for a client who is human immunodeficiency virus (HIV) positive. Which complication associated with this diagnosis is most important for the nurse to teach prevention strategies?

Infection

A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. What should the nurse do to prepare the client for the procedure?

Instruct the client to void

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply.

Mental confusion Flapping hand tremors Musty, sweet breath odor

A nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent?

Stress ulcer

What determines if a client will develop AIDS from an HIV infection?

The number of CD4+ T-cells available

A client with cirrhosis of the liver and ascites has been taking chlorothiazide, a thiazide diuretic. Why did the provider add spironolactone to the client's medication regimen?

To help prevent potassium loss

The nurse is teaching a burns safety class. Which examples should the nurse use to describe the usual occupational hazards for burn injuries? Select all that apply.

road tar electrical power lines cooking grills fertilizers

What is the most important test the nurse should check to determine whether a transplanted kidney is functioning?

serum creatinine

Which organism would the nurse explain is consistent with a protozoal infection in clients with acquired immunodeficiency syndrome (AIDS)?

toxoplasmosis