lippincotts nclex rn review for med surg test 1
19 . The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the: • 1. Similarities from one side to the other. • 2. Changes from the normal expected findings. • 3. Appearance of age-related wrinkles. • 4. Skin turgor.
19 . 2 . Noting changes from the normal expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system.
1 . There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply. • 1. An 8-year-old with third-degree burns over 10% of his body surface area (BSA). • 2. A 20-year-old who inhaled the smoke of the fire. • 3. A 50-year-old diabetic with first- and second degree burns on his left forearm (about 5% of his BSA). • 4. A 30-year-old with second-degree burns on the back of his left leg. • 5. A 40-year-old with second-degree burns on his right arm (about 10% of his BSA).
1 . 1, 2, 3. Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their body surface area (BSA), clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients on my age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.
10. The nurse should plan to begin rehabilitation efforts for the burn client: • 1. Immediately after the burn has occurred. • 2. After the client's circulatory status has been stabilized. • 3. After grafting of the burn wounds has occurred. • 4. After the client's pain has been eliminated.
1 0 . 2 . Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state of health and independence. It is not possible to completely eliminate the client's pain; pain control is a major challenge in burn care.
11 . During the early phase of burn care the nurse should assess the client for? • 1. Hypernatremia. • 2. Hyponatremia. • 3. Metabolic alkalosis. • 4. Hyperkalemia.
11 . 4 . Immediately after a burn, excessive potas sium from cell destruction is released into the extra cellular fluid. Hyponatremia is a common electro lyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of sodium bicarbonate.
12 . Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube? A client who has: • 1. Electrical burns of the hands and arms causing arrhythmias. • 2. Thermal burns to the head, face, and airway resulting in hypoxia. • 3. Chemical burns on the chest and abdomen. • 4. Secondhand smoke inhalation.
12 . 2 . Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does
13 . A client is receiving fluid replacement with Lactated Ringer's after 40% of his body was burned 10 hours ago. The assessment reveals: temperature 36.2° C; heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 mL for the last 2 hours. The I.V. rate is currently at 375 mL/hour. Using the SBAR (Situation-Background-Assessment Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for: • 1. Furosemide (Lasix). • 2. Fresh frozen plasma. • 3. I.V. rate increase. • 4. Dextrose 5%.
13 . 3 . The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is Lactated Ringer's solution, Normal Saline, or albumin.
14 . After the initial phase of the burn injury, the client's plan of care will focus primarily on: • 1. Helping the client maintain a positive self concept. • 2. Promoting hygiene. • 3. Preventing infection. • 4. Educating the client regarding care of the skin grafts.
14 . 3 . The inflammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There is a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate durin the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection.
15 . The rate at which I.V. fluids are infused is based on the burn client's: • 1. Lean muscle mass and body surface area (BSA) burned. • 2. Total body weight and BSA burned. • 3. Total BSA and BSA burned. • 4. Height and weight and BSA burned.
15 . 2 . During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight. Total surface area is estimated by taking into account the individual's height and weight. Height is not a common variable used in formulas for fluid replacement.
16 . The nurse is conducting a focused assess of the gastrointestinal system of a client with a burn injury. The nurse should assess the client for: • 1. Paralytic ileus. • 2. Gastric distention. • 3. Hiatal hernia. • 4. Curling's ulcer.
16 . 4. Curling's ulcer, or gastrointestinal ulceration, occurs in about half of the clients with a burn injury. The incidence of ulceration appears proportional to the extent of the burns and the ulceration is believed to be caused by hypersecretion of gastric acid and compromised gastrointestinal perfusion. Paralytic ileus and gastric distention do not result from hypersecretion of gastric acid and stress. Hiatal hernia is not necessarily a potential complication of a burn injury.
17 . In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? • 1. Oral analgesics such as ibuprofen (Motrin) or acetaminophen (Tylenol). • 2. Intravenous opioids. • 3. Intramuscular opioids. • 4. Oral antianxiety agents such as lorazepam (Ativan).
17 . 2 . The severe pain experienced by burn clients requires opioid analgesics. In addition, opioids such as morphine sedate and alleviate apprehension. Oral analgesics such as ibuprofen The Client with Health Problems of the Integumentary System 6 8 7 or acetaminophen are unlikely to be strong enough to effectively manage the intense pain experienced by the client who is severely burned. Because of the altered tissue perfusion from the burn injury, intravenous medications are preferred. Antianxiety agents are not effective against pain
18 . Using the Parkland Formula, calculate the hourly rate of fluid replacement with Lactated Ringer's solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%. mL/hour.
18 . 750 mL/hour. Lactated Ringer's solution 4 mL x weight in kg x TBSA; half given over the first 8 hours and half given over the next 16 hours. 4 mL x 75 kg x 40= 12,000 mL or 4 mLx75 kg x40 1 750 mL 2 x — = 8 hours 2 hour 12,000 mL x I = 6,000 mL z 6,000 mL 8 hours = 750 mL/hour
20 . Which of the following changes are associated with normal aging? • 1. The outer layer of skin is replaced with new cells every 3 days. • 2. Subcutaneous fat and extracellular water decrease. • 3. The dermis becomes highly vascular and assists in the regulation of body temperature. • 4. Collagen becomes elastic and strong.
20 . 2 . With age, there is a decreased amount of subcutaneous fat, muscle laxity, degeneration of elastic fibers, and collagen stiffening. The outer layer of skin is almost completely replaced every 3 to 4 weeks. The vascular supply diminishes with age. Collagen thins and diminishes with age.
21 . Which of the following should the nurse expect to assess as normal skin changes in an elderly client? Select all that apply. • 1. Diminished hair on scalp and pubic areas. • 2. Dusky rubor of left lower extremity. • 3. Solar lentigo. • 4. Wrinkles. • 5. Xerosis. • 6. Yellow pigmentation.
21 . 1 , 3 , 4 , 5. Skin changes associated with aging include the following: Diminished hair on scalp and pubic areas, solar lentigo (liver spots), wrinkles, and xerosis (dryness). Dusky rubor of the left lower extremity may indicate the individual has a venous stasis problem in the affected extremity and is gen erally associated with "unsuccessful aging." Yellow pigmentation of the skin that may be associated with liver inflammation is generally known as jaundice.
22 . The nurse will anticipate which of the fol lowing problems that can result for the older adult undergoing abdominal surgery? • 1. Increased scarring. • 2. Decreased melanin and melanocytes. • 3. Decreased healing. • 4. Increased immunocompetence.
22 . 3 . Normal aging consists of decreased proliferative capacity of the skin. Decreased collagen syn thesis slows capillary growth, impairs phagocytosis among older clients, and results in slow healing. Increased scarring is not a result of age-related skin changes. Both melanin and melanocytes give color to the skin and hair but are increased with aging. There is a decrease in the immunocompetence of the aging client.
23 . Health maintenance and promotion activities are especially important for the older adult. Which of the following activities reflects a health maintenance activity for an otherwise healthy older adult? • 1. Drinks 1,500 mL of fluids per day. • 2. Consumes a balanced diet of 1,200 calories per day. G 3. Walks briskly for 10 minutes three times per week. • 4. Sleeps at least 8 hours each night.
23 . 1 . Drinking at least six 8-oz glasses of fluid per day helps the client stay well hydrated. Maintaining optimal fluid balance is important for all body systems. Caloric intake varies according to an individual's size and activity level. An intake of 1,200 calories/day may be insufficient for some older clients. Walking 10 minutes/day is useful, but an otherwise healthy older client should try to walk 20 minutes/day. It is important to get adequate rest; however, the amount of sleep needed varies with the individual.
24 . Which of the following characteristics would put a client at the greatest risk for impaired wound healing after abdominal surgery? • 1. Age 75 years. • 2. Age 30 years, with poorly controlled diabetes. • 3. Age 55 years, with myocardial infarction. • 4. Age 60 years, with peripheral vascular dis ease.
24 . 2. Poorly controlled diabetes is a serious risk factor for postoperative wound infection. Other factors that delay wound healing include advanced age, nutritional deficiencies (vitamin C, protein, zinc), inadequate blood supply, use of corticosteroid, infection, mechanical friction on the wound, obesity, anemia, and poor general health.
26 . A 90-year-old male complains of feeling cold in his room even though the thermostat is set at 75° F (24° C). The client probably feels cold because older adults have: • 1. Increased cellular cohesion. • 2. Increased moisture content of the stratum corneum. • 3. Slower cellular renewal time. • 4. Decreased ability to thermoregulate.
26 . 4 . Older clients have a decreased thermoregulation that is related to decreased blood sup ply and reabsorption of body fat. As a result, older adults are at risk for hypothermia. Cellular cohesion and moisture content diminish with age and cellular renewal time is slowed; however, these do not result in impaired thermoregulation.
27 . Palpation of the skin provides the nurse useful information regarding: • 1. Bruising of the skin. • 2. Color of the skin. • 3. Hair distribution. • 4. Turgor of the skin.
27 . 4 . Assessment of the integumentary system includes both inspection and palpation. Palpation involves assessing temperature, turgor, moisture, and texture. Observing bruises and color and detecting hair distribution are inspection.
28 . A priority nursing diagnosis for an adult female who has pruritus and is continuously scratching the affected areas and demonstrates agitation and anxiety regarding the itching sensation would be: • 1. Risk for infection related to pruritus. • 2. Ineffective health maintenance related to lack of knowledge of the disease process. • 3. Impaired skin integrity related to dehydration from the treatment medications. • 4. Social isolation related to poor self-image.
28 . 1. Risk for infection related to pruritus is the priority nursing diagnosis because it has been documented that the client continues to scratch the affected areas. Satisfactory control of the itching sensation and discomfort associated with scratching may relieve the agitation and anxiety. More information is required regarding the knowledge level of the client and her disease process, but learning cannot take place when an individual's attention is distracted with pruritus. Impaired skin integrity is a potential problem if the client continues to scratch the affected areas and destroys the skin, but the risk of infection deserves priority attention because of the client's anxiety. There are no data to support that the client has a poor self-image.
29 . The nurse is applying a hand mitt restraint for a client with pruritis (see figure). The nurse should first: 1. Verify the physician order to use the restraint. 2. Secure the mitt with ties around the wrist tied to the bed frame. 3. Place a folded pillow under the wrist. Z 4. Place the mitt on top of the hand.
29 . 1 . Before using any restraints, the nurse must verify that a physician has written an order for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmar surface of the hand.
3 . During the emergent (resuscitative) phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation? • 1. Serum creatinine level of 2.5 mg/dL. • 2. Little fluctuation in daily weight. • 3. Hourly urine output of 60 mL. • 4. Serum albumin level of 3.8.
3 . 1. Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine out put should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/hour. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP read ings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 gm/dL.
30 . An older adult client in stage 2 of Parkinson's disease is being discharged with cellulitis of the right lower extremity. Which of the following nursing diagnoses will guide the discharge teaching? Select all that apply. • 1. Ineffective tissue perfusion related to decreased cardiac output. • 2. Impaired skin integrity related to barrier changes of the skin. • 3. Risk for injury related to environmental hazards. • 4. Impaired verbal communication related to dysarthria. • 5. Activity intolerance related to painful lower extremity.
30 . 2 , 3 . Usual aging is associated with dry skin; however, seborrhea (oily skin and dandruff) is one result of the biochemical changes associated with Parkinson's disease. The client with Parkinson's disease has a higher risk of skin breakdown due to the moist and oily skin. To maintain skin integrity, a client with Parkinson's disease needs frequent skin care and aeration of the skin. Gait instability in a client with Parkinson's disease is a result of muscle rigidity, change in the center of gravity, and gait shuffling. Because of these changes in gait and balance, the client is at higher risk for injuries in the environment, such as hitting furniture or obstacles in the client's path. As a result, the environment should be evaluated for potential injury or falls. Tissue perfusion and verbal communication are not problems typically associated with Parkinson's dis ease. The client should not experience activity intolerance from the cellulitis or Parkinson's disease.
33 . The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should: • 1. Use a fluorescent light source to assess the skin. • 2. Inspect the skin only when the Braden score is above 12. • 3. Look for skin color that is darker than the surrounding tissue. • 4. Avoid touching the skin during inspection.
33 . 3 . When assessing a client with dark skin, the nurse should observe for skin that is darker, brownish, purplish, or bluish compared to surrounding skin. Fluorescent light casts a blue light making skin assessment difficult; natural or halogen light sources help to accurately assess the skin. Risk assessment using the Braden Scale should be performed on all clients. A Braden score of 12 indicates a high risk for pressure ulcer and the lower the Braden score, the higher the risk (no risk 19-23, at risk 15-18, moderate risk 13-14, high risk 10-12, and very high risk 9 or below). The nurse should touch the skin to assess consistency and temperature differences. ulcers have full-thickness skin breakdown. In stage IV ulcers, the bone, muscle, and supporting tissue are involved. The nurse should immediately initiate plans to relieve the pressure, ensure good nutrition, and protect the area from abrasion.
34 . The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" x 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart? 1. Stage I pressure ulcer. • 2. Stage II pressure ulcer. • 3. Stage III pressure ulcer. • 4. Stage IV pressure ulcer.
34 . 2. Stage I pressure ulcers appear as nonblanching macules that are red in color. Stage II ulcers have breakdown of the dermis. Stage III ulcers have full-thickness skin breakdown. In stage IV ulcers, the bone, muscle, and supporting tissue are involved. The nurse should immediately initiate plans to relieve the pressure, ensure good nutrition, and protect the area from abrasion.
35 . A Stage II pressure ulcer is characterized by: • 1. Redness in the involved area. • 2. Muscle spasms in the involved area. • 3. Pain in the involved area. • 4. Tissue necrosis in the involved area.
35 . 3 . A stage II skin breakdown involves epidermal sloughing and pain. Redness without blanching is noted in stage I. Stage III involves tissue necrosis with subcutaneous involvement. Stage IV involves muscle or bone destruction. Muscle spasms are not a criterion used in the staging process.
36 . The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply. • 1. Elevate the head of the bed to 50 degrees. • 2. Obtain daily cultures • 3. Cover with protective dressing • 4. Reposition the client every 2 hours • 5. Request an alternating-pressure mattress
36 . 3 , 4 , 5 . The client has a Stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing.. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees. All wounds have bacteria and obtaining frequent cultures (unless ordered otherwise) are not necessary.
37 . The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness and the area was classified as a Stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, the nurse should do which of the following first? • 1.Instruct the home health aid to reposition the client every 2 hours while the client is awake. • 2.Ask the client's daughter to purchase a foam mattress. • 3.Contact the physician to request a hydrocolloid dressing. • 4.Suggest that the client ask a neighbor to purchase antibiotic cream at the drugstore.
37 . 3 . The pressure ulcer has changed from Stage I to Stage II and requires the use of a protective dressing. Repositioning and use of foam mattresses are appropriate interventions for Stage I pressure ulcers. There is no indication that the ulcer is infected.
38 . Which of the following factors places a client at greatest risk for skin cancer? 1. Fair skin and history of chronic sun exposure. 2. Caucasian race and history of hypertension. 3. Dark skin and family history of skin cancer. 4. Dark skin and history of hypertension.
38 . 1 . Caucasians who have fair skin and a high exposure to ultraviolet light are at increased risk for malignant neoplasms of the skin. The other risk factors include exposure to tar and arsenicals and family history. History of hypertension is a coronary artery disease risk factor. Clients with dark skin have increased melanin and are not as prone to skin cancer.
4 . A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," the nurse would determine that about what percentage of the client's body surface has been burned? • 1. 18%. • 2. 27%. • 3. 45%. • 4. 64%.
4 . 3. According to the rule of nines, this cli ent has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.
40 . The nurse is developing a program on skin cancer prevention for a community group. Which of the following should be included in the program? Select all that apply. 1. Purchase sunscreen containing benzophe nones to block UVA and UVB rays. 2. Use sunscreen with a minimum of 15 sun protection factor (SPF). 3. Obtain genetic screening to identify risk of melanoma. • 4. Apply sunscreen only on sunny days, espe cially between 10 AM and 2 PM. • 5. Have a pigmented lesion biopsied by shaving if it looks suspicious. G 6. Rub baby oil to lubricate skin before going out in the sun.
40 . 1 , 2 . Sunscreen should be applied 20 to 30 minutes before going outside, even in cloudy weather. Sunscreen with a minimum of 15 SPF should be used. Sunscreen containing benzophenones block both UVA and UVB rays. The rays of the sun are most dangerous between 10 a.m. and 2 p.m. Genetic screening is not indicated, although a mutated gene has been identified in some families with high incidence of melanoma. A prior diagnosis of melanoma and having a first-degree relative diagnosed with melanoma increases a person's risk. Lesions should not be shave-biopsied; excisional biopsy technique is used. Baby oil will increase the adverse effects of sun exposure; sunscreen protection should be used.
41 . A client with malignant melanoma asks the nurse about the prognosis. The nurse should base a response that informs the client that the prognosis depends on: 1. The amount of ulceration of the lesion. 2. The age of the client. 3. The location of the lesion on the body. 4. The thickness of the lesion.
41 . 4 . Tumor or lesion thickness is the predictive factor for survival. Cutaneous melanoma that is confined to the epidermis has a high cure rate. Asymmetry, border, color, and diameter are known as the "ABCDs" of melanoma. Thus, the amount of ulceration, age, and location are not clearly associated with the prognosis.
42 . The nurse finds an unlicensed assistive per sonnel massaging the reddened bony prominences of a client on bed rest. The nurse should: • 1. Reinforce the aide's use of this intervention over the bony prominences. 2. Explain that massage is effective because it improves blood flow to the area. • 3. Inform the aide that massage is even more effective when combined with lotion during the massage. 4. Instruct the aide that massage is contraindicated because it decreases blood flow to the area.
42 . 4. Massaging areas that are reddened due to pressure is contraindicated because it further reduces blood flow to the area. The UAP should not massage the bony prominences or use lotion on the area. Massage does improve circulation and blood flow to muscle areas; however, because the area is reddened, the client is at risk for further skin breakdown.
44 . A client has been admitted with draining foot lesions. The nurse should do which of the following? Select all that apply. 1. Place the client in a room with negative air pressure. 2. Admit the client to a semi-private room. 3. Admit the client to a private room. 4. Post a "contact isolation" sign on the door. 5. Wear a protective gown when in the client's room. 6. Wear latex-free gloves when providing direct care.
44 . 3 , 4 , 5 . Infection control policies must be followed to prevent the spread of infection. Until the pathogens are identified, the client must be isolated in a private room. Utilizing contact isolation, wearing a protective isolation gown and clean gloves, in addition to following isolation protocol to exit the room, may aid in the prevention of spread of infectious agents to others. A draining foot lesion does not require a negative air pressure room, which is primarily reserved for preventing spread of tuberculosis. Latex free gloves are not needed unless the client has a latex allergy.
45 . The nurse is to administer an antibiotic to a client with burns now, but there is no medication in the client's medication box. What should the nurse do first? 1. Inform the unit's shift coordinator. 2. Contact the client's physician. 3. Call the pharmacy department. 4. Borrow the medication from another client.
45 . 3. By contacting the pharmacy to report the absence of the medication, the pharmacy can bring the medication to the client's medication box. From there on, the pharmacy can make sure the correct medications are present. Contacting the shift coordinator or the client's physician will not correct the original cause of the variance. It is never appropriate to "borrow" a medication from another client.
5 . A priority nursing diagnosis for a client with burns during the emergent period would be: • 1. Excess fluid volume. • 2. Imbalanced nutrition: Less than body requirements. • 3. Risk for injury (falling). • 4. Risk for infection.
5 . 4. Infection is a priority problem for the burned victim because of the loss of skin integrity and alteration in body defenses. Excess fluid or imbalanced nutrition is not a priority during the emergent period. A risk for falling is not a priority for this client because the client would be on bed rest and most likely in a critical care unit.
6 . Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing change? 1. Soak the dressing. 2. Remove the dressing. 3. Administer an analgesic. 4. Slit the dressing with blunt scissors.
6 . 3 . Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.
7 . The client with a major burn injury receives total parenteral nutrition (TPN). The expected out come is to: 1. Correct water and electrolyte imbalances. 2. Allow the gastrointestinal tract to rest. 3. Provide supplemental vitamins and minerals. 4. Ensure adequate caloric and protein intake.
7. 4. Nutritional support with sufficient calo ries and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns, mak ing oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of I. V. fluids with electrolyte addi tives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vita-
8. An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they appear to help: • 1. Encourage formation of tough skin. • 2. Promote the growth of epithelial tissue. • 3. Provide for permanent wound closure. • 4. Facilitate development of subcutaneous tis
8. 2. Biologic dressings such as porcine grafts serve many purposes for a client with severe bums. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth of subcutaneous tissue.
2 . The nurse in the immediate care clinic is assessing an 80-year-old client who lives with his son's family and has scald burns on his hands and both forearms (first- and second-degree burns on 10% of his body surface area). What should the nurse do first? • 1. Clean the wounds with warm water. • 2. Apply antibiotic cream. • 3. Refer the client to a burn center. 4. Cover the burns with a sterile dressing.
2 . 3. The nurse should have the client transited to a burn center. The client's age and the extent of the burns require care by a burn team id the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.
25 . An 82-year-old female has several eccimotic areas on her left arm. The nurse should further assess the client for: • 1. Elder abuse. • 2. Self-inflicted injury. • 3. Increased capillary fragility and permeabilitv. • 4. Increased blood supply to the skin.
25 . 3 . The aging process involves increased cap illary fragility and permeability. Older clients have a decreased amount of subcutaneous fat. Therefore, there is an increased incidence of bruiselike lesions caused by collection of extravascular blood in the loosely structured dermis. In addition, older clients do not always realize that injury has occurred because of a diminished awareness of pain, touch, and peripheral vibration. There are no data to sup port elder abuse or self-inflicted bruises. Blood sup ply to the skin declines with aging.
31 . An alert and oriented elderly client is admit ted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client? • 1. Keep all the lights on in the room at all times. • 2. Use a nightlight in the bathroom. • 3. Keep all four side rails up at all times. • 4. Place the client in a room with a camera monitor.
31 . 2 . Many falls occur when older clients attempt to get to the bathroom at night. The risk is even greater in an unfamiliar environment. Use of a nightlight in the bathroom enables the older adult client to see the way to the bathroom. Keeping the lights on in the room at all times may contribute to sensory overload and prevent adequate rest. Raised side rails paradoxically contribute to falls when the older client tries to climb over them to get to the bathroom. The upper side rails may be raised, but it is not recommended that all four side rails be elevated. Camera monitoring can be used but does nothing to prevent a fall.
32 . Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to: • 1. Altered balance. • 2. Altered protective pressure sensation. • 3. Impaired hearing ability. • 4. Impaired visual acuity.
32 . 2 . Pressure ulcers usually occur over bony prominences. An alteration in the protective pres sure sensation results from a decline in the number of Meissner's and pacinian corpuscles. Older adults do have altered balance that may result in falls, but not skin breakdown. Impaired hearing and vision do not contribute to pressure ulcers.
39 . A nurse is providing teaching to a client about skin cancer. Which of the following should the nurse explain are risk factors for skin cancer? Select all that apply. 1. Increasing age. Z 2. Exposure to chemical pollutants. Z 3. Long-term exposure to the sun. 4. Increased pigmentation. 5. Genetics. 6. Immunosuppression.
39 . 1 , 2 , 3,5,6. Risk factors associated with skin cancer include: Age, exposure to chemical pollutants, exposure to the sun, genetics, and immunosuppression. As individuals age, the risk of developing skin cancer increases. Long-time exposure to the sun and exposure to chemical pollutants (nitrates, coal, tar, etc.) increases the risk of skin cancer. Individuals who have less skin pigmentation (i.e., fair, blue-eyed people) have a higher risk of skin cancer because they tend to incur sunburns rather than tan. Family history plays a role in cancer. Regardless, immunosuppressed individuals are at a higher risk for the development of any type of cancer, as the body's defenses are not functioning properly.
43 . The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five clients were diagnosed with pressure ulcers. The nurse manager should: 1. Use benchmarking procedures to compare the findings with other nursing units in the hospital. • 2. Ask the staff education department to con duct an educational session about preventing pressure ulcers. Z 3. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes. Z 4. Conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers.
43 . 3 . The problem of pressure ulcers in hospitalized clients is best addressed by using quality improvement techniques to identify the problem, determining strategies for improvement, and setting 6 9 0 The Nursing Care of Adults with Medical and Surgical Health Problems goals for outcomes. Benchmarking for comparison will indicate where this nursing unit compares with other units, but does not address the problem for this unit; having clients with pressure ulcers on any unit is not acceptable. Educational programs are more effective after there is an understanding of the problem. Chart audits and blaming do not solve the problem or address quality improvement measures.
9 . Which of the following factors would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? • 1. Absence of infection in the wounds. • 2. Adequate vascularization in the grafted area. • 3. Immobilization of the area being grafted. • 4. Use of analgesics as necessary for pain relief.
9. 4. Analgesic administration to keep a burn victim comfortable is important but is unlikely to influence graft survival and effectiveness. Absence of infection, adequate vascularization, and immo bilization of the grafted area promote an effective graft.
