Exam 4 Review

Bilirubin

breakdown of RBCs

Foods high in calcium

broccoli and shrimp

Filtration

the movement of water through the semipermeable membrane due to pushing force hydrostatic pressure) on one side of the membrane.

Hypotonic

too much water than sodium (0.5 half normal saline)

Hypertonic

very very low sodium, more salt than water (3% normal saline)

Wherever potassium goes:

water follows

Acute Phase (INCLUDES DIURETIC STAGE)

· This phase begins 36 to 48 hr after injury when the fluid shift resolves. · Priorities include data collection and maintenance of the cardiovascular, respiratory, and gastrointestinal systems (including nutrition); wound care; pain control; and psychosocial interventions. · Phase ends with closure of the wound.

Rehabilitative Phase

· This phase begins when most of the burn area has healed. · Phase ends when the client achieves the highest level of functioning possible. · Priorities include psychosocial support; prevention of scars and contractures; and resumption of activities, including work, family, and social roles. · This phase can last for years.

A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

"As long as I change my gloves between clients, it is not necessary to wash my hands."

A nurse is reinforcing teaching to a client about skin cancer. Which of the following statements by the client indicates a need for further teaching?

"Eating a high fiber diet will reduce my risk for developing skin cancer."

A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?

"How do you handle stress?"

A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SiO2 is 89 %. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 50 mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?

. Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.

Give meds containing calcium

30 min before meals

pottassium

9% intracellular

Fluid Volume Deficient (FVD) (hypovalemia)

Dehydration of cells, loss of extra cellular fluid (ECF)

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

Hardened skin

hydrochlorathiazide (HCTZ)

Increase absorption of calcium

A nurse is collecting data from a client who has basal cell carcinoma on her nose. Which of the following findings should the nurse expect?

Small, translucent nodule

CO2/O2

an example of diffusion

Hypercalcemia (Cal >10.6)

calcium leaves bone, excess calcium and vitamin D

Hypovolemia

can be caused by abnormal excess fluid loss, N/V, diarrhea, hemorrhage, and wound drainage

Excess Fluid Volume (EFV)

can be caused by many reasons ( IV Therapy & Renal Failure)

Hypernatremia >145

cells swell and shrinks

Osmosis

diffusion of water

Hyperkalemia (K+>5.0)

disruption of cell membrane, shift of K+ from ICF to ECF

3rd Space Shift

fluid going into the tissues

ANP (atrial natriuretic peptide)

helps with water/salt regulation, balance of BP, and basal dilation

Hyponatremia <135

loss of sodium, excessive of water ( swollen puffy cells, too much water intake)

Electrolytes

minerals that help maintain the body's fluid balance & deals w/ muscle

Albumin

protein in blood; maintains the proper amount of water in the blood; keeps fluid in the vascular system

active transport

requires cellular energy and uses ATP-requiring pump energy (sodium-potassium pump)

Hematocrit (HCT)

tells a ratio between RBCs and water

BUN

tells fluid volume, dehydration, and fluid overload

BNP (brain natriuretic peptide)

tells if you are having heart failure if over 400

Specific Gravity

tells the concentration of urine

A nurse is contributing to the plan of care for a client who has herpes zoster. Which of the following actions should the nurse recommend including in the plan of care?

Apply cool compresses to the affected area.

passive transport

Diffusion, osmosis, filtration

Isotonic

Perfect with body (9% normal saline) (crystaloids)

A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will clean and dry the area before applying the patch."

A nurse is reinforcing discharge teaching with a client about dietary sources of potassium. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat cantaloupe for my morning snack."

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

"Large incisions will be made in the burned tissue to improve circulation."

A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter. Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?

"My baby's fingers are looking swollen."

A nurse is reviewing discharge instructions with a client who has pruritus following treatment for scabies. Which of the following instructions should the nurse include?

"Wear loose fitting clothing while you are experiencing itching."

parkland formula for burns

% BSA x weight (kg) x 4 give 1/2 fluids in first 8 hours. remaining 1/2 in last 16 hours.

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

A client who has swelling and tenderness around the wound

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

A deep crater without visible bone, tendon, or muscle

A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?

Change gloves between sites when providing wound care to multiple wounds.

CO2

Alkaline <35-45> ACID

A nurse is caring for a child who has atopic dermatitis. Which of the following findings should the nurse expect?

Rash with thick skin

CO3

ACID <22-26> ALKALINE

pH

ACID <7.35-7.45> ALKALINE

A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include?

Administer pain medication 30 min before physical therapy.

A nurse is reinforcing teaching with a parent of a child who has eczema. Which of the following instructions should the nurse include in the teaching?

Apply a cool, wet compress to the affected area.

A nurse is assisting with the care of a client who is brought to the emergency department and has burn injuries. Which of the following findings should the nurse identify the client has a deep partial-thickness burn?

Burned area red in color with eschar present

During a change-of-shirt report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?

Check the client's respiratory rate and lung sounds.

A nurse in a provider's office is collecting data from a client who reports pruritus and reddened, fluid-filled vesicles on her lower leg. The nurse should suspect which of the following disorders?

Contact dermatitis

A nurse in a pediatric clinic is collecting data from a preschool-age child who has suspected impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection?

Red macule with honey-colored crusts

A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?

Erythema

A nurse is caring for a client following the application of an aquathermia pad. Which of the following manifestations should the nurse identify as an indication that the client has a superficial burn?

Erythema (REDNESS)

Chrosteks sign (hypocalcemia)

Face twitching

Parkland formula is a

Fluid Resuscitation Formula uses the Rule of Nines to determine TBSA percentage effected to determine how much fluid the patient will need in the first 24 hours after the burn injury

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

Fully recollapse the reservoir after emptying it.

A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?

Granulation tissue

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?

IV insertion site

A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?

Identify the clients at greatest risk for development of pressure ulcers.

A nurse is preparing to administer IV vancomycin to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse plan to take?

Infuse the medication over at least 60 min.

A nurse is collecting data from a client who has AIDS. The nurse notes that the client has multiple, widespread purplish-brown skin lesions. The nurse should suspect that the client has developed which of the following types of skin lesions?

Kaposi's sarcoma

A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids should the nurse use in the first 24 hr following a client's burn injury?

Lactated Ringer's

Hypokalemia (K+<3.5)

Low potassium

Anything with KDA is:

Metabolic Acidosis

A nurse is caring for an adolescent client who comes to the provider's office for treatment of acne vulgaris on her cheeks. Which of the following instructions should the nurse reinforce with this client and her parents?

Minimize sun exposure.

GI System

Non-Sterile

A nurse is assisting in planning an educational session regarding risk factors for skin cancer to a group of clients. Which of the following information should the nurse plan to include in the session? (Select all that apply.)

Overexposure to ultraviolet light Chronic skin irritations Genetic predisposition

A nurse is collecting data from a client who has herpes zoster (shingles). Which of the following is an expected finding?

Painful vesicles following a nerve pathway

A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?

Pinch up a fold of skin to check for turgor.

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

Purulent

Trousseau Sign (hypocalcemia)

Put BP on and pump up hand then it contracts

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. Which of the following ECG results should indicate to the nurse that the medication has been effective?

Reduction of T wave amplitude

Hypocalcemia (Cal <8.4)

Renal failure and removal of parathyroid

A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?

Reports of exposure to a skin irritant

A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer?

Sun exposure

A nurse is reinforcing teaching with a client who has a superficial lesion. A biopsy indicates malignant melanoma. Which of the following treatment choices should the nurse include in the teaching?

Surgical excision

A nurse is reinforcing teaching about possible treatments with a client who has psoriasis. Which of the following treatment options should the nurse include in the teaching? (Select all that apply.)

Tar preparations Corticosteroids Ultraviolet light therapy

A nurse is collecting date on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority?

The client produces black colored sputum

A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse?

The wound has a halo of erythema on the surrounding skin.

Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?

There is full-thickness skin loss with a crater.

A nurse is assisting with the admission of a client who has an open wound that is infected from community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA). The client's wound has not responded to treatment with surgical drainage. The nurse should anticipate that the client will require which of the following interventions?

Trimethoprim/sulfamethoxazole (BACTRIM)

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

Vitamin C

A nurse is reinforcing teaching with an adolescent who has warts on his hands. Which of the following instructions should the nurse should include?

Warts on the hands are usually not painful.

A nurse is reinforcing medication teaching with a client who has psoriasis and a new prescription for triamcinolone cream. Which of the following statements should the nurse include in the teaching?

Wrapping plastic around the site can increase the medication's effectiveness.

Emergent (resuscitative phase)

· This phase begins with the injury and continues for 24 to 48 hr. · Initial fluid shift (occurs in the first 12 hr and continues for 24 to 36 hr) Priorities include securing the airway, supporting circulation and organ perfusion by fluid replacement, managing pain, preventing infection through wound care, maintaining body temperature, and providing emotional support