EXAM 4 practice questions:

We know we cant treat graft-versus-host disease, but which two medications give to "PREVENT" it?

-Methotrexate -Cyclosporine

Pertaining to a Chemical burn injury, the nurse instructs the employees that which is the first consideration in immediate care?

-Removing all clothing, including gloves, shoes, and any undergarments

Pertaining to a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report?

-an elevated H&H

Pertaining to a patient with burns who is immunocompromised, what precautions should be taken to prevent infection?

-avoid placing fresh flowers or plants in or near the clients room -avoid crowds -avoid fresh fruits

Extensive burn injury 45% of total body surface area: planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period?

-between 18 & 24hours after the injury

How does rejection present in a patient who has had a heart transplant?

-dysrhythmias

_______ determines if recipient has high or low sensitivity to potential donors.

PRA (panel of reactive antibodies) A high PRA indicates that the person has a large number of cytotoxic antibodies and is highly sensitized, which means there is a poor chance of finding a cross match-negative donor.

A ________________ cross-match means that the recipient has cytotoxic antibodies to the donor, which is an absolute contraindication in living donor transplants.

Positive

A patient weight 100kg with a TSBA of 19%, in calculating the lactated ringers fluid resuscitation that is needed what is the answer?

-7,600mL —>within the first 24hours 4mLX100kgX19(TBSA)

-occurs in stem-cell transplant -The graft (donated tissue) rejects the host (recipient) tissue -occurs 7-30days after transplantation -once it starts little can be done to alter the course What type of disease am i?

(GVHD) graft-versus-host disease

The client has partial thickness burns to the anterior legs & perineum. Using the rule of nines, calculate the % of total body surface area affected.

-1% peri-area -18% Right % Left anterior legs Answer :19% TBSA

Pertaining to the rule of 9s: The head & neck are worth how much percentage?

-4.5% anterior -4.5% posterior 9% in total

A client comes to the emergency department after sustaining burns from a house fire. The client has 27% total body surface area that is affected by the burns. What are the priority nursing actions? SATA 1. Immerse the client in cool water 2.remove as much of the clients clothing as possible 3. Administer opioid analgesics as prescribed 4. Flush the clients eyes with tap water 5. Initiate two intravenous lines 6. Insert an indwelling urinary catheter

2, 3,5,6

___ degree (superficial partial thickness, partial thickness) into dermis.

2nd

A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which action would the nurse take? 1. Turn eyelashes inward toward the eyeball. 2. Wrap sterile gauze around the face. 3. Cover the face with ointment and gauze. 4. Apply ointment only without the use of gauze.

3 Rationale The face is highly vascular and may become edematous after a thermal burn. It should be covered with ointment and gauze to prevent vascularization and swelling. The nurse should ensure that the eyelashes are not turned inward. Wrapping gauze around the face will create pressure on delicate facial structures. The gauze is required to cover the face after the application of ointment to prevent infection.

A male client sustains burns and is brought to the emergency department for care. The client is estimated to weigh 160lbs. The client is estimated to have 25% of his body burned. Using the parkland formula, how much lactated ringers should be administered in the first eight hours of his care?

3635mL

___ degree (deep partial thickness and full thickness) dermis to the hypodermis.

3rd

What is the Parkland formula?

4 ml of LR x wt(kg) x % of body burned (TBSA)

___ degree underlying structures such as bone and muscle

4th

kidney and bone marrow are high risk for rejection (when pertaining to organ transplants) and require ___ to ___ HLA antigen matches

5-6 They are more vascular.

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In helping the patient decide about treatment, the nurse informs the patient that a. successful transplantation usually provides better quality of life than that offered by dialysis. b. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available. c. hemodialysis replaces the normal functions of the kidneys, and patients do not have to live with the continual fear of rejection. d. the immunosuppressive therapy after transplantation makes the person ineligible to receive other treatments if the kidney fails

A

The nurse is alerted to possible anaphylactic shock immediately after a patient has received IM penicillin by the development of a. edema and itching at the injection site. b. sneezing and itching of the nose and eyes. c. a wheal-and-flare reaction at the injection site. d. chest tightness and production of thick sputum

A

Emerging and reemerging infections affect health care by (select all that apply) a. reevaluating vaccine practices. b. revealing antimicrobial resistance. c. limiting antibiotics to those with life-threatening infection. d. challenging researchers to discover new antimicrobial therapies

A, B, D

Pain management for the burn patient is most effective when (select all that apply) a. a pain rating tool is used to monitor the patient's level of pain. b. painful dressing changes are delayed until the patient's pain is completely relieved. c. the patient is informed about and has some control over the management of the pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury

A, C, D

Interventions to prevent health care-associated infections include (select all that apply) a. following hand-washing protocols. b. limiting visitors to persons over age 18. c. placing high-risk patients in private rooms. d. decontaminating equipment used for patient care. e. appropriately using personal protective equipment

A, D, E

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters. b. exposed fascia. c. exposed muscles. d. intact nerve endings. e. red, shiny, wet appearance

A, D, E

-occurs within 6 months -pt could have developed antibodies over time -not uncommon, pt will usually have at least 1 episode -usually reversible with additional immunosuppressant therapy. -increased risk for infection & cushings with this type. What type of rejection am i?

Acute rejection

Pertaining to oxygen requirements for growth of organisms is blood cultures, which "requires" oxygen and which requires "N0 oxygen"?

Aerobic: requires oxygen Anaerobic: requires N0 oxygen

In a person having an acute rejection of a transplanted kidney, what would help the nurse understand the course of events (select all that apply)? a. A new transplant should be considered. b. Acute rejection can be treated with OKT3. c. Repeated episodes of acute rejection can lead to chronic rejection. d. Corticosteroids are the most successful drugs used to treat acute rejection. e. Acute rejection is common after a transplant and can be treated with drug therapy

B, C, E

Which statement(s) describe(s) the management of a patient following lung transplantation (select all that apply)? a. High doses of O2 are administered around the clock. b. Using a home spirometer will help to monitor lung function. c. Immunosuppressant therapy usually involves a 3-drug regimen. d. Most patients have an acute rejection episode within the first 2 days. e. A lung biopsy is done using a transtracheal method if rejection is suspected

B, C, E

If your patient has a "true allergy" to Penicillin and the doctor prescribes Cephalosporin instead. What is your next action? A) administer the medication as prescribed B) question the order C) make sure they take the medication on a full stomach D) clock out an call yo mama

B. Cephalosporin is related to penicillin and if they are having a true allergy to the penicillin you need to make sure you are asking your pt what their symptoms are and if they are severe enough you need to contact the HCP.

-occurs over months or years -can occur after repeated episodes of acute rejection -occurs for unknown reasons -fibrosis & scarring occurs -irreversible What type of rejection am i?

Chronic rejection

_____________ is done to determine the existence of antibodies against the potential donor.

Cross-match. The cross match uses serum from the recipient mixed with donor lymphocytes to test for any preformed anti-HLA antibodies to the potential donor organ.

A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Which action is the most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again. b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the provider

D

After abdominal surgery, Mrs.Bauer's blood culture results came back as "no growth". The tech reported the following noon vital signs: B/P 88/72, HR:102, RR:26, Temp:101.4. What is the nurses priority action? A) administer Tylenol as ordered for temp greater than 101 B) encourage oral intake and hold PM dose of atenolol C) no action is needed as these vital signs are unchanged from the 0800 measurements D) SBAR and immediately notify the HCP with a recommendation/concern of developing sepsis/septic shock.

D

What is the total body surface area and degree of burn for the client that sustained burns to the anterior right leg that appears reddened and blanches easily? A) 10%; 2nd degree B) 4%; 1st degree C) 5%; 2nd degree D) 9%; 1st degree

D- For the client that sustains a burn, it is important to assess the skin to determine the size and depth of burn injury. This is estimated in comparison with the total body surface area (TBSA). Burn wounds are classified based on the depth of the skin injury. The first degree burn involves damage to the epidermis. The skin will appear red and dry, with blanching assessed.

You have a 27 year old male patient admitted with diverticulitis who has been prescribed Metronidazole (Flagyl) what patient teaching is important with this medication?

Do not drink alcohol

True or False: Stevens-Johnson syndrome/Toxic epidermal necrolysis are caused by a bacterial skin infection.

False- these skin reactions are caused by an abnormal immune response triggered by certain medications.

You have a 28 year old female patient admitted with a yeast infection, you suspect the doctor to prescribe __________________ to treat it.

Fluconazole

__________ is used in matching organs and tissues. They are antigens responsible for organ rejection.

HLA (human leukocyte antigen)

Teaching for client with end stage kidney disease awaiting kidney transplant:

Hemodialysis sometimes needed after surgery, and this is done to help the body accommodate to that new kidney.

-Occurs within 24hrs -recipient had pre-existing antibodies -no treatment —-> remove the organ What type of rejection am i?

Hyper-acute rejection

What is our biggest problem pertaining to graft-versus-host diseased patients?

INFECTION—-> Granulocytopenia which is an abnormally low concentration of certain white blood cells called granulocytes in the blood. This condition reduces the body's resistance to many infections.

What causes Antimicrobial-resistant infection?

MRSA is caused by over use or improper use of antibiotics

A ________________cross-match means that no preformed antibodies are present, and it is safe to go ahead with transplant.

Negative

In a patient who has graft-versus-host disease what am i going to monitor for in my patient?

Skin monitor for rash on palms & soles of feet. Liver monitor for jaundice,elevated liver enzymes, hepatic coma. GI monitor for diarrhea, abdominal pain, GI bleeding, malabsorption.

A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care team is planning for discharge. The first action the nurse should take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. teach the patient and the caregiver proper wound care to be performed at home. c. review the patient's current health care status and readiness for discharge to home. d. give the patient written information and websites for information for burn survivors

c. review the patient's current health care status and readiness for discharge to home.

Pertaining to _____________________ (medication) we know we monitor the therapeutic level; Peak & trough. The lowest level of the drug in the patient's body is called the trough level. The peak for a drug is when the level of the drug in the patient's body is the highest.

Vancomycin If the trough is "HiGH" right before the next dose is due, we would HOLD the medication to prevent toxicity. The trough is supposed to be "L0W" when we administer the next dose.

A kidney transplant recipient has had fever, chills, and dysuria over the past 2 days. What is the first action that the nurse should take? a. Assess temperature and initiate workup to rule out infection. b. Reassure the patient that this is common after transplantation. c. Provide warm covers to the patient and give 1 gram oral acetaminophen. d. Notify the nephrologist that the patient has manifestations of acute rejection

a. Assess temperature and initiate workup to rule out infection.

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments. b. repositioning the patient every 2 hours. c. performing active ROM at least every 4 hours. d. massaging the new tissue with water-based moisturizers

a. applying pressure garments.

To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, high-carbohydrate diet. b. increase normal caloric intake by about four times. c. eat at least 1500 calories/day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balance

a. eat a high-protein, high-carbohydrate diet.

A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day

b. observe the wound for signs of infection during dressing changes

Which prevention strategy would the nurse include when teaching about home fire safety? a. Set hot water temperature at 140°F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Do not allow older adults to cook unattended.

c. Encourage regular home fire exit drills.

Association between HLA antigens and diseases is most commonly found in what disease conditions? a. Cancers b. Infectious diseases c. Neurologic diseases d. Autoimmune disorders

d. Autoimmune disorders

What accurately describes rejection after transplantation? a. Hyperacute rejection can be treated with OKT3. b. Acute rejection can be treated with sirolimus or tacrolimus. c. Chronic rejection can be treated with tacrolimus or cyclosporine. d. Hyperacute reaction can be avoided if crossmatching is done before transplantation

d. Hyperacute reaction can be avoided if crossmatching is done before transplantation.

The nurse tells a friend who asks him to administer his allergy shots that a. it is illegal for nurses to administer injections outside of a medical setting. b. he is qualified to do it if the friend has epinephrine in an injectable syringe provided with his extract. c. avoiding the allergens is a more effective way of controlling allergies, and allergy shots are not usually effective. d. immunotherapy should only be administered in a setting where emergency equipment and drugs are available.

d. immunotherapy should only be administered in a setting where emergency equipment and drugs are available.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?

lactated ringers solution

The nurse is caring for a client with full thickness burns covering 20% of their body. What is the priority of care after ensuring a patent airway?

-IV fluids

Pertaining to the rule of 9s: The arms are worth how much percentage?

-4.5% front -4.5% back 9% in total

Amphotericin B

-Antifungal medication. -nasty side effects -THiNK—> Ampho-Terriibbbllleeeee (= -side effects such as chills, nausea etc -medication works great though so just give antihistamine w/ it.

When performing a venipuncture for a blood culture what is the recommended way to collect the specimen?

-Below the IV site -Two different sets of culture (aerobic/anaerobic), each collected from a separate site (arms) -30 minutes apart

The nurse instructs firefighters that in the event of a tar burn, which is the immediate action?

-Cooling the injury with water

What's the number 1 intervention for major burns in the first 24hrs?

-IV Lactated Ringers (LR) solution -V Normal saline (0.9% sodium chloride)

Client has full thickness burns to all posterior body surfaces. Using the rule of nines, calculate the % of total body surface area affected.

-head =4.5% -Back =18% -Right arm & left arm =9% -Right & left leg =18% Answer is 49.5% TBSA

Patient teaching for Cyclosporine + Azathioprine

-immunosuppressant drug -risk for infection + bleeding -report leukopenia -no grapefruit juice -birth control -use a soft toothbrush -you will take this medication for life -take at the same time everyday -no live vaccines -HCP will evaluate blood work regularly -no pregnant patients -before giving check WBC + Plts

__________ & ____________ can be used to lower the number of antibodies in highly sensitized patients (high PRA).

-plasmapheresis -IV immunoglobulin (IVIG)

How does rejection present in a patient who has had a kidney transplant?

-urine output -BUN -Creatine -potassium *Think about the function of the organ*

Discharge teaching to a client with partial thickness burns (second degree burns) on the hand include:

-wrap the fingers with "individual" dressings This is done to prevent tissues from sticking together and causing further damage to the skin

Which patients are appropriate for the nurse to refer to the burn center? Select all that apply. 1. A patient with burns of the feet 2. A patient with an inhalation injury 3. An elderly patient with third-degree burns 4. A patient with burns involving minor joints 5. A patient with partial-thickness burns involving 8% of total body surface area

1, 2, 3

Which discharge instructions would the nurse include when teaching a patient with partial-thickness burns on the hands about rehabilitation at home? Select all that apply. 1. Recommend exercises. 2. Take low-dose antihistamines. 3. Protect healed areas from direct sunlight. 4. Apply water-based creams on healed areas. 5. Inform the patient that wound care is not required at home.

1, 2, 3, 4 Rationale The nurse should advise the patient to take low-dose antihistamines because these can be used at bedtime if itching persists. The nurse should instruct the patient to protect healed areas from direct sunlight for 3 months to prevent hyperpigmentation and sunburn injury. Only water-based creams that penetrate into the dermis should be used routinely on healed areas to keep the skin supple and well moisturized. This helps to decrease itching and flaking. The nurse should also encourage the patient to perform physical and occupational therapy routines and recommended exercises. The patient may have small, unhealed wounds, and it is therefore important to carry out dressing changes and wound care at home.

The nurse is teaching a community group about immediate actions to be taken in the case of burns to more than 10% of body surface area. Which reason would the nurse provide for avoiding the use of ice on the burned body part? Select all that apply. Ice can cause hypothermia. Ice can cause vasoconstriction. Ice can stop further tissue damage. Ice can reduce blood flow to the burned area. Ice can increase the blood flow to the burned area.

1, 2, 4

Which precautions would the nurse take to protect a patient with burns on the face and the ears from further damage? Select all that apply. 1. Avoid using pillows. 2. Keep ears free from pressure. 3. Apply a heavy gauze dressing for fast healing. 4. Wrap ears with sterile gauze after applying ointment. 5. Elevate the patient's head by placing a rolled towel under the shoulders.

1, 2, 5 Rationale The ears should be kept free from pressure because of their poor vascularization and tendency to become infected. Avoid using pillows because the pressure on the ear cartilage may cause chondritis, and the ear may adhere to the pillowcase, causing pain and bleeding. The patient's head is elevated by placing a rolled towel under the shoulders to reduce pressure over the ears, which helps to prevent pressure necrosis. A heavy gauze dressing should not be applied because it can put pressure on the ears and damage them. The ears are not wrapped with sterile gauze after applying ointment in order to avoid pressure over the ears.

Which interventions would the nurse expect to see included in the plan of care for a patient with partial- and full-thickness burns on the lower extremities? Select all that apply. 1. Escharotomy care 2. Administration of diuretics 3. Daily cleansing and debridement 4. Application of topical antimicrobial agent 5. IV and oral pain medications

1, 3, 4, 5 Rationale Pain control is essential in the care of a patient with a burn injury. Daily cleansing and debridement, as well as the application of an antimicrobial ointment, are expected interventions used to minimize infection and enhance wound healing. An escharotomy (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

Which initial interventions would the nurse perform as a part of emergency burn management for a patient who has sustained full-thickness burns covering more than 20% of the total body surface area? Select all that apply. 1. Begin fluid replacement. 2. Avoid supplemental oxygen. 3. Cover burned areas with dry dressings. 4. Lower the burned limbs below the heart level. 5. Establish IV access with two large-bore catheters.

1, 3, 5 Rationale Begin fluid replacement to compensate for fluid loss. Cover the burned areas with dry dressings to begin the healing process and thus prevent contamination. IV access should be established with two large-bore catheters to enable large amounts of fluid replacement. Supplemental oxygen is required to maintain adequate perfusion. The injured limb should be kept elevated above the heart level to prevent and decrease swelling.

The nurse and health care provider plan to provide an antioxidant regimen for a patient with partial-thickness burns in the acute phase. Which antioxidants would the nurse identify as being included in the protocol? Select all that apply. 1. Zinc 2. Astaxanthin 3. Chlorophyll 4. Selenium 5. Multivitamins

1, 4, 5 Zinc is an antioxidant and also a part of the antioxidant protocol because it supports cell growth and development. Selenium is used in the antioxidant protocol because it helps to prevent cell damage. Multivitamins are a part of the antioxidant protocol because they help to compensate for the nutritional deficiencies of essential vitamins and minerals. Astaxanthin and chlorophyll are antioxidants but are not a part of the antioxidant protocol. Calcium is important to maintain strong bones and teeth, but it is not included in the antioxidant protocol.

What are the signs that fluid resuscitation has been effective in a burn patient?

1. 30mL/hr or more of urine output 2. Blood pressure (90/systolic or more) 3. Heart rate less than 120/min

List 6 contraindications of a recipient selection for a kidney transplant:

1. Disseminated malignancies 2. Refractory/untreated cardiac disease 3. Chronic respiratory failure 4. Extensive vascular disease 5. Chronic infection 6. Unresolved psychosocial disorders

As per the Parkland (Baxter) formula, the estimated total fluid requirement in the first 24 hours for a severely burned patient who weighs 80 kg and has burns on more than 40% of the total body surface area (TBS) would be ________ mL. Record your answer using a whole number and no punctuation.

12800 According to the Parkland (Baxter) formula: 4 mL of lactated Ringer's solution should be administered per kilogram (kg) of body weight per percentage of TBS burned in the first 24 hours after the burn. For an 80-kg patient with a 40% TBSA burn, 4 mL × 80 kg × 40 TBSA burned = 12,800 mL in 24 hours.

___ degree (superficial) epidermis only

1st

Which patient signs and symptoms noted during triage would indicate to the nurse an upper airway injury? Select all that apply. Dyspnea Hoarseness Difficulty swallowing Copious secretions Carbonaceous sputum

2, 3, 4 An inhalation injury in the upper airway involves the mouth, oropharynx, and/or larynx. It may cause hoarseness in the voice because of the effect on the larynx. There may be difficulty in swallowing because of the involvement of the mouth and oropharynx. There may be copious secretions in response to the injury to the airway. The injury to the lower airway involves the trachea, bronchioles, and alveoli and may cause carbonaceous sputum and dyspnea.

During the first 24 hours after the female client sustained a 40% total body surface area (TBSA) burn, which lab value result is expected? Select all that apply. 1. Potassium of 4.2 mg/dL 2. Sodium of 139 mg/dL 3. White blood cell of 8000 per mm 4. hemoglobin of 18 g/dL 5. Hematocrit of 54%

4 & 5 Changes in laboratory test values are found in different phases of recovery after a burn is sustained. The resuscitation/emergent phase is the first phase of a burn injury. This occurs at the onset of the injury and continues through the first 48 hours after. During this phase the lab value changes will be related to the fluid shift and direct tissue damage. The potassium level (3.5-5.0 mEq/L) will be increased as a result of the disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis. Sodium (136-145 mEq/L) is trapped in edema fluid and lost through plasma leakage causing a decreased level. The hemoglobin (F 12-16 g/dL) and hematocrit (F 37-47%) will be elevated as a result of fluid volume loss that results in hemoconcentration.

A nurse is inserting an intermittent catheter in a female client who sustained full and partial thickness burns to the chest and abdomen. In what order would the nurse perform these actions? 1. Open packet of lubricant and lubricate catheter 2. Clean labia and urinary meatus 3. Place sterile drape on bed between clients thighs 4. Insert catheter into urethral meatus 5. Apply sterile gloves 6. Perform hand hygiene

6 5 3 1 2 4

Pertaining to the rule of 9s: The legs are worth how much percentage?

9% for the front 9% for the back 18% in total

The nurse caring for a client with partial-thickness burns expects which findings upon assessment? A) areas of painful redness without elevation B) areas of painful, filled-fluid blisters C) areas of dry, painless leathery skin D) areas of black, cherry red or white patches

B

The nurse informs the patient with a bacterial pneumonia that the most important factor in antibiotic treatment is: A. Antibiotics should have been used to prevent pneumonia. B. All of the supplied antibiotics should be taken even when symptoms have resolved. C. Enough antibiotics for 2 days treatment should be reserved in case symptoms recur. D. Patients should get antibiotics for any infection to prevent development of streptococcal-related disease.

B

The nurse is caring for a client who was in a house fire and has full-thickness burns on the back of both arms and the back of the head. The client's face has superficial burns on the face. The client weighs 60kg. Using the rule of nines and the Parkland formula with 4mL lactated ringers IV, how much IV fluid does the client need in the first 24hrs following the burns? A) 1620mL B) 3240mL C) 4320mL D) 8640mL

B

When caring for a patient with an electrical burn injury, which prescription from the health care provider would the nurse question? A. Urine for myoglobin B. Lactated Ringer's at 25 mL/hr C. Mannitol 75 gm IV D. Sodium bicarbonate 24 mEq every 4 four hours

B Electrical injury_puts the patient at risk for myoglobinuria, which can lead to acute tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2 to 4 mL/kg% total body surface area (TBSA), a rate sufficient to maintain urinary output at 75 to 100 mL/hr. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in the prevention and treatment of AT. Mannitol also can be used to maintain urine output. The urine would also be monitored for the presence of myoglobin. Sodium bicarbonate may be given to alkalinize the urine.

A patient's partial-thickness burn injuries were debrided and covered with a silver-impregnated dressing a week ago. Today the nurse notes the wounds have been fully debrided. Which would be the nurse's priority intervention for wound care at this time? A. Reapply a new dressing without disturbing the wound bed. B. Apply fine-meshed petroleum gauze to the debrided areas. C. Wash the wound aggressively with sterile saline three times a day. D. Apply cool compresses for pain relief in between dressing changes.

B Rationale When the partial-thickness burn wounds have been fully debrided, a protective, coarse- or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. The nurse would not wash the wound aggressively with saline three times daily, apply cool compresses, or apply a new dressing at this time.

You have a patient admitted yesterday with pneumonia and he is yelling down he hallway for his medications, you just got to work and look at the orders in the computer in which he just received and order of Macrolide from the doctor. Before you go to the med cart to pull it you double check his charts and notice he has a history of gall stones and A-fib but no known allergies to this drug. What is your next action as a nurse? A) administer the medication as prescribed B) Hold the medication and contact the HCP C) give him a glass of grapefruit juice to take his medicine with D) make him wait to punish him for yelling in your unit

B. Macrolide (Zithromax-Z'pack) causes cardiac dysrhythmias so you need to make sure you don't give to patients with a history of A-Fib

A nurse is caring for a client who has third-degree burns on the right hand from a kitchen fire. The client is scheduled to go for a skin graft procedure tomorrow. Physical therapy is coming within the hour. The client is sitting in the room with the lights out and is staring out the window. What action does the nurse take first? A) Provide client education about the upcoming skin graft and sign the informed consent for surgery. B) Assess the status of the dressing on the clients hand. C) Say to the client, "People with burns experience a lot of emotions and frustrations. Tell me what you are feeling right now." D) Help the client put on shoes and get ready for the physical therapy visit.

C

An adult client was severely burned in a house fire. The client has second degree burns on the right leg and right arm as well as the back. Using the rule of nines, the nurse estimates the percentage of the burns as which of these options? A. 25% B. 32% C. 45% D. 50%

C

The nurse has an order to draw blood cultures on his/her patient. After following the proper procedure for specimen collection and transport to the laboratory, the nurse discovers that the specimen collection bottles had exceeded their expiration date. What is the nurse's priority action? A) notify the lab to use an ARB bottle to transfer the specimen and compensate for the expired medium. B) notify the HCP to get an order to run the blood cultures as ordered. C) notify the lab to discard the specimen and redraw the blood cultures D) no action is necessary as this will not impact the blood culture results

C

The nurse is administering IV fluids to a client who sustained full-thickness burns on the front of both legs and the feet. The client weighs 55kg. What finding by the nurse indicates the effectiveness of fluid resuscitation? A) mean arterial pressure (MAP) 40mmHg B) systolic blood pressure of 82mmHg C) urine output 30mL in the last hour D) heart rate 130 beats per min

C

While providing care for a client that sustained a 4th degree burn, which clinical presentation is expected? Select all that apply. A) painful blisters surrounding the wound B) presence of blanching around the wound C) presence of intense pain at site D) wound is blackened and depressed E) wound extends into the muscle and bone

D & E Burn wounds are classified based on the depth of the skin injury. The first degree burn involves damage to the epidermis. The skin will appear red and dry, with blanching assessed. The second degree burn involves injury to the epidermis and dermis and presents as a painful blistered area. The third degree burn is a full thickness burn that involves the epidermis, dermis, and subcutaneous tissue area. The skin will have a white, leathery, charred black appearance with the absence of blanching. The fourth degree burn extends from the epidermis into the muscle/bone area. The wound is blackened and depressed, and sensation is completely absent.

What is the total body surface area (TBSA) of injury for the client that sustained a burn, anterior arms and head/neck, as well as the chest and abdomen? A) 0,27 B) 0,45 C) 0,18 D) 0,32

D- For the client that sustains a burn, it is important to assess the skin to determine the size and depth of burn injury. This is estimated in comparison with the total body surface area (TBSA). The most used method to estimate TBSA is the rules of nine. With this system, the head and neck is 9% (4.5% anterior, 4.5% posterior), the perineal area is 1%. The arms are 9% (4.5% anterior, 4.5% posterior) each and the legs are 18% ((9% anterior, 9% posterior) each. The anterior torso (chest 9%, abdomen 9%) and posterior torso (upper/mid back 9% and lower back/buttocks 9%) are 18% each.

When assessing a client with full thickness burns, the nurse expects: A) small, fluid filled blisters covering the area that has been burned B) decreased heart rate and increased blood pressure C) hyperactive bowel sounds with decreased digestion D) dry, leathery, waxy-white tissue

D- Full thickness burns destroy the first two layers of the skin, the epidermis and dermis, They appear very dry, leathery, and may appear white, red, or dark brown. There are no blisters associated with full thickness burns.

The injury that is least likely to result in a full-thickness burn is a. sunburn. b. scald injury. c. chemical burn. d. electrical injury

a. sunburn Rationale: Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current.

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, a pulse of 110, and urine output of 20 mL over the past hour. The nurse reports the findings to the physician and anticipates which of the following prescriptions? a. transfusing 1 unit of packed red blood cells b. administering a diuretic to increase urine output c. increasing the amount of IV lactated Ringers solution administered per hour d. changing the IV lactated Ringer's solution to one that contains dextrose in water.

c. fluid management during the first 24 hours following a burn injury generally includes the infusion of LR solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30mL/hr. 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, should expect ↑ of LR's.

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls. b. movement of potassium into the vascular space. c. movement of sodium and water into the interstitial space. d. hemolysis of red blood cells from large volumes of rapidly administered fluid

c. movement of sodium and water into the interstitial space.

How is SJS & TEN diagnosed?

skin biopsy