Exam 3 Med Surge PP questions

A fair-skinned 32-year-old client whose mother recently died from Squamous Cell Carcinoma asks the nurse, "What can I do to prevent Squamous Cell Carcinoma from developing?" The best response by the nurse is that a. The avoidance of excessive sun exposure will decrease the risk b. Individuals with fair skin and blue eyes are at increased risk c. Malignant melanoma is a relatively rare type of skin cancer d. The client is at high risk for melanoma because of family history

a. The avoidance of excessive sun exposure will decrease the risk

Which nursing intervention would be most helpful in managing a patient newly admitted with cellulitis of the right foot? a. Apply warm, moist heat b. Wrapping the foot snugly in blankets c. Encouraging frequent ambulation d. Not elevating the affected extremity

a. Apply warm, moist heat

The patient has dry skin and pruritus on the legs that causes the patient to scratch at the skin uncontrollably. What measures can the nurse use to help stop the itch/scratch cycle? Select all that apply. a. Moisturize the skin on the legs b. Provide a warm blanket and room c. Administer antihistamines at bedtime d. Use careful hand washing after rubbing her legs e. Cleanse the legs with a saline solution twice daily

a. Moisturize the skin on the legs c. Administer antihistamines at bedtime d. Use careful hand washing after rubbing her legs ?

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. a pain rating tool is used to monitor the patient's level of pain 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)

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

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. blisters d. intact nerve endings e. red, shiny, wet appearance

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

Persons with dark skin are more likely to develop a. keloids. b. wrinkles. c. skin rashes. d. skin cancer.

a. keloids.

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

The nurse assessed the patient's skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called a. wheals. b. papules. c. pustules. d. plaques.

a. wheals.

A client is admitted with second- and shird degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? a. 18% b. 22.5% c. 27% d. 36%

b. 22.5%

In preparation for a client being admitted with herpes zoster, what does the nurse do? (Select all that apply.) a. Prepare a room for reverse isolation b. Assess staff for a history of or vaccination for chickenpox c. Check the admission orders for analgesia d. Choose a roommate who also is immune suppressed e. Ensure that gloves are available in the room

b. Assess staff for a history of or vaccination for chickenpox c. Check the admission orders for analgesia e. Ensure that gloves are available in the room

Which action will be included in the plan of care for a client who has burns of the early head, neck, and right arm and hand? a. Place the right arm and hand flexed in a position of comfort b. Elevate the right arm and hand on pillows and extend the fingers c. Assist the client to a supine position with a small pillow under the head d. Position the client in a side-lying position with rolled towel under the neck

b. Elevate the right arm and hand on pillows and extend the fingers

A client is admitted to the burn unit with burns of the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the client to cough and auscultate the lungs again b. Notify the HCP and prepare for endotracheal intubation c. Document the results and continue to monitor the client's RR d. Reposition the client in high-Fowler's position and reassess breath sounds

b. Notify the HCP and prepare for endotracheal intubation

Diagnostic testing is recommended for skin lesions when a. a health history cannot be obtained. b. a more definitive diagnosis is needed. c. percussion reveals an abnormal finding. d. treatment with prescribed medication has failed.

b. a more definitive diagnosis is needed.

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

The primary function of the skin is a. insulation. b. protection. c. sensation. d. absorption.

b. protection.

Age-related changes in the hair and nails include (select all that apply) a. oily scalp. b. scaly scalp. c. thinner nails. d. thicker, brittle nails. e. longitudinal nail ridging.

b. scaly scalp. d. thicker, brittle nails. e. longitudinal nail ridging.

A client with severe burns has fluid replacement ordered. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 350 mL/hr b. 523 mL/hr c. 938 mL/hr d. 1250 mL/hr

c. 938 mL/hr 1875 mL/hr ÷ by 2 = 938mL/hr

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

On inspection of a patient's dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. This assessment finding is called a. vitiligo. b. intertrigo. c. Nevus of Ota. d. telangiectasia.

c. Nevus of Ota.

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

During the physical examination of a patient's skin, the nurse would a. use a flashlight in a poorly lit room. b. note cool, moist skin as a normal finding. c. pinch up a fold of skin to assess for turgor. d. perform a lesion-specific examination first and then a general inspection.

c. pinch up a fold of skin to assess for turgor.

When assessing the nutritional-metabolic pattern in relation to the skin, the nurse asks the patient about a. joint pain. b. the use of moisturizing shampoo. c. recent changes in wound healing. d. self-care habits related to daily hygiene.

c. recent changes in wound healing.

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

In which order will the nurse take these actions when doing a dressing change for partial-thickness burn wound on a client's chest? a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze. c. Apply silver sulfadiazine cream. a. Apply sterile gauze dressing. b. Document wound appearance.

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. Anticipate the need for endotracheal intubation and notify the provider