Integumentary Disorder
The nurse is caring for a 15 year old who has suffered 3rd degree burns to 30% total burn surface area (TBSA). The health care provider has ordered morphine 0.5 mg by mouth every 3 to 4 hours as needed for pain. The elixir comes in 2mg/1mL. How many milliliters would the nurse give?
0.25
A 2-year-old child has been diagnosed with cellulitis. The health care provider has order the client to get ceftriaxone 50 mg IM. The pharmacy sends 100 mg/2 mL. The nurse will administer the medication in the vastus lateralis. How many milliliters should be administered? Record your answer using a whole number.
1
The nurse is instructing a client after the administration of a Mantoux test. Which statement from the client indicates an understanding of the information given by the nurse?
"A Mantoux test is a screening for tuberculosis"
The parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of methicillin resistant staphylococcus aureus (MRSA) at the camp. What education can the nurse reinforce in order to help with prevention of this infection? Select all that apply.
"I'm sorry, but I can't share confidential information"
A licensed practical nurse is assisting a triage nurse in the emergency department admit a client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned?
36
The nurse is reinforcing prior education for a client on how to prevent development of basal cell epithelioma. Which information is MOST important for the nurse to tell the client?
Avoid exposure to sun.
The nurse is reinforcing education to parents of an infant about burn prevention. Which instructions should be reinforced regarding burns from tap water ?
Before putting the infant in the tub, test the water with a hand.
A nurse is reviewing a newly admitted client's chart. Based on this progress notes entry, the nurse knows these data are consistent with which condition?
Carbon monoxide poisoning
A college student living in the dormitory comes to the school health clinic stating " I think I have a ringworm on the bottom of my foot." What education should the nurse reinforce after treatment to prevent reoccurrence? Select all that apply
Change socks at least once a day Be sure to wear shower shoes when using a public shower. Keep skin clean and dry.
A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?
During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth.
The licensed practical nurse is collecting a wound culture from a clients gaping surgical incision. Which would the nurse consider to ensure proper culture collection?
Gently roll a sterile swab from the center of the wound outward to collect drainage.
The nurse is reinforcing education to a group of adolescents on acne. Which statement by an adolescent would show that the teaching has been effective?
Hormonal changes is a cause of acne
A nurse is caring for a client who is at risk for skin breakdown. To decrease the risk, the nurse must help ensure that the client remains adequately hydrated. Which action can the nurse take to help determine the client's fluid needs?
Measure intake and output
A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V route. The nurse should monitor the client fro which adverse reaction to this drug?
Ototoxicity
A client has a foot ulcer that hasn't shown signs of improvement over the last several months. What medical condition is most likely causing the wound healing delay?
Peripheral vascular disease
The nurse is caring for a wheelchair bound client. Which piece of equipment impedes circulation to the area it is meant to protect?
Ring or donut
The nurse is reinforcing education for a client taking tetracycline for severe inflammatory acne. Which instructions are important to reinforce?
Take the drug 1 hour before or 2 hours after meals with large amounts of water.
The nurse is caring for a client with a wound that requires sharp debridement. When the client requests pain medication prior to the procedure, the health care provider (HCP) responds, "This is a quick procedure, so that is not necessary." The HCP begins to set up a sterile field. How should the nurse respond?
Tell the HCP the nurse will administer the prescribed PRN analgesic and the procedure can be started in 20-30 minutes.
The parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of methicillin resistant staphylococcus aureus (MRSA) at the camp. What education can the nurse reinforce in order to help with prevention of this infection? Select all that apply.
Wash hands with soap and water regularly. Keep cuts and scrapes clean and covered. Avoid sharing towels and razors with others.
A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may:
dislodge the autografts.
