Test 5

A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the dient?

Presence of soot around the nasal passages

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?

Sodium deficit

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized the nurse's technique. How should the nurse best interpret this client's behavior?

The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output of 20 ml/hour

Which zone consists of the area where the injury is most severe and deepest?

coagulation

An elderly client has been diagnosed with metastatic cancer and has a poor prognosis of survival. The family asks the nurse for advice on whether to tell the client of the diagnosis or to keep it quiet. Which is the best response from the nurse?

"In my experience, clients who know are more likely to be involved with their plan of care."

A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery?

"Tumor removal will promote comfort."

A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is

"You will need to practice birth control measures."

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?

"Are the burns associated with chemicals used in the plant?"

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm?, Which statement by the client indicates a need for additional teaching?

"I floss my teeth every morning"

The hospice nurse has just admitted a new client to the program. What principle guides hospice care?

Care addresses the needs of the client as well as the needs of the family.

While administering an intravenous chemotherapeutic medication to a client, the nurse assesses swelling at the insertion site. What is the nurse's first action?

Discontinue the intravenous medication

The nurse manager is orienting a new nurse to the oncology unit. When reviewing the safe administration of antineoplastic agents, which action should the nurse manager emphasize?

Dispose of the antineoplastic wastes in the hazardous waste receptacle.

A client has been burned significantly in a workplace accident. Which conditions create the need for immediate intensive care by specifically trained personnel? Select all that apply.

Fluid loss Fluid shift Hypotension

A nurse is reviewing a client with a radioactive implant for the treatment of cervical cancer. What is the nurses best action?

Place the client in a private room

Which of the following laboratory findings, would be identified by the nurse as the greatest risk for a cancer client scheduled for implantable port?

Platelet count 98,000/mm3

A client with a recent history of Gl disturbance has been scheduled for a barium study. The physician ordered this particular test for this client because it will:

Show movement of the GI tract

The results of a 22-year-old college student's most recent Papanicolaou (Pap) test are suggestive of cervical cancer. Since learning of this news, the client has asked numerous questions of all members of the health care team about she could have gotten cancer. What client teaching should the nurse at the clinic prioritize in this patient's care?

The relationship between viruses and cervical cancer

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

pain management

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn?

preexisting conditions

The nurse is caring for a client with a benign breast tumor. The tumor may have which characteristic?

slow rate of growth

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply.

• Place the client in a horizontal position. • Roll the client in a blanket to smother the fire.

A client is cared for in a burn unit after suffering partial-thickness burns. The dient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply.

•this medication is an antibacterial •the medication will be applied directly to the wound •this medication will help my burn heal

An oncologist advises a client with an extensive family history of breast cancer to consider a mastectomy. What type of surgery would the nurse include in teaching?

prophylactic

A client has experienced burns covering the back and front of both legs. Using the Rule of Nines, what percentage would the nurse assign to the client's injury when documenting? Fill in the blank with a number.

36

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care?

Acute

Your patient has recently completed her first round of chemotherapy in the treatment of lung cancer. When reviewing this mornings blood work what findings would be suggestive of myelosuppression

Decreased platelets and red blood cells

A patient with uterine cancer is being treated with internal radiation therapy. What would the nurse's priority responsibility be for this patient?

Explain to the patient that she will continue to emit radiation while the implant is in place.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?

Lund and Browder method

The nurse is caring for a client who has just been told that stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the client the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer?

Palliative care

The nurse is providing education to a client that is scheduled for mechanical débridement of a wound. The nurse knows that mechanical débridement involves which element?

Removal of Eschar until the point of pain and bleeding occurs

After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The dient's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, which nursing diagnosis takes priority?

Risk for infection

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood?

The client is likely experiencing a delayed onset of respiratory complications

The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA) which can be caused by many factors, or carcinogens. What factors can be carcinogenic? Select all that apply.

dietary substances environmental factors viruses