PE

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 Rationale: Cerebral cells require high levels of oxygen. When the partial pressure of oxygen within the circulatory system falls, the client becomes restless, and cognitive functions become impaired. With kidney failure the client becomes progressively confused and lethargic because of the buildup of toxins in the body. Hypovolemic shock is more likely to occur in the emergent (resuscitation) phase. With metabolic acidosis the client is lethargic.

A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve?

Preventing pressure on peripheral blood vessels Rationale: The circulating air bed disperses body weight over a larger surface, which reduces pressure against the capillary beds, allowing for tissue perfusion. These beds are used for clients who are immobile; they do not increase mobility. Limiting orthostatic hypotension is achieved by dangling, not by this type of bed. Range-of-motion exercises, not the type of bed, will help prevent contracture.

After reviewing the laboratory reports of a client with a severe joint injury, the nurse suspects fat embolism syndrome (FES). Which findings support the nurse's suspicion? Select all that apply.

Fat cells in the urine PaO2 value of 58 mm Hg (7.73 kPa) Hematocrit value of 30% (0.30) Rationale: Fat cells in the urine, PaO2 of 58 mm Hg (7.73 kPa), and hematocrit of 30% (0.30) are all indicative of fat embolism syndrome (FES). FES is characterized by the presence of systemic fat globules, which are distributed into tissues and organs after a traumatic skeletal injury. The presence of fat cells in the urine indicates FES. Fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis that produces signs and symptoms of acute respiratory distress syndrome (ARDS) and decreased partial pressure of arterial oxygen. The normal partial pressure of arterial oxygen is 80 to 100 mm Hg (10.6-13.33 kPa). The normal hematocrit value is 40% to 50% (0.40-0.50). Poor oxygen exchange decreases the hematocrit value in a client with FES. The normal platelet count is in the range of 150,000 to 450,000 platelets per µL of blood (150-450 x 109/L). The platelet count is decreased in FES. A platelet count of 160,000/µL (160 x 109/L) is a normal finding. Normal prothrombin time is in the range of 12 to 13 seconds. Prothrombin time is prolonged in FES, but a prothrombin time of 12 seconds is normal.

After a large fire, many people were admitted to the emergency department. The nurse noticed many clients with moist blebs and blistered skin with a cherry red color that are hypersensitive to touch or air. What types of injuries are identified in these clients?

Second-degree burns Rationale: The characteristic findings in second-degree burns are moist blebs and blisters on the skin. The skin appears to be a mottled white, pink to cherry-red color. The skin is also hypersensitive to touch or air and there may be moderate to severe pain. Clients with first-degree burns have redness, pain, moderate to severe tenderness, and minimal edema. In third- and fourth-degree burns, the skin is dry and leathery. The skin is waxy white, dark brown, or charred in appearance with a strong burn odor.