Workbook: Chapters 11, 17, 18, 19, 22, 23, 24,

Early excision and grafting of burn wounds involve excising ___________ down to clean viable tissue and applying a(n) _________ whenever possible.

- eschar (or necrotic tissue) - autograft

Which statement characterize malignant melanomas (select all that apply)? A. Related to chemical exposure B. Neoplastic growth of melanocytes. C. Skin cancer with highest mortality rate D. Irregular color and asymmetric shape E. Frequently occurs on previously damaged skin.

ANS: B. Neoplastic growth of melanocytes. C. Skin cancer with highest mortality rate D. Irregular color and asymmetric shape Rationale: Malignant melanomas are neoplastic growths of melanocytes, have the highest mortality rate of skin cancers, and are irregular color and asymmetric shape. Squamous cell carcinoma frequently occurs in previously damaged skin

Chapter 23 Which statements are true about the skin and skin care(select all that apply)? a. One of the detrimental effects of obesity on the skin is increased sweating. b. The nutrient that is critical in maintaining and repairing the structure of epithelial cells is vitamin C. c. Exposure to UVA rays is believed to be the most important factor in the development of skin cancer. d. The photosensitivity caused by various drugs can be blocked by the use of topical hydrocortisone. e. Photosensitivity results when certain chemicals in body cells and tissues absorb light from the sun and release energy that harms the tissues and cells. f. When teaching a patient about the use of sunscreens that protect against exposure to both UVA and UVB rays, the nurse advises the patient to look for inclusion of benzophenones.

ANS: a. One of the detrimental effects of obesity on the skin is increased sweating. e. Photosensitivity results when certain chemicals in body cells and tissues absorb light from the sun and release energy that harms the tissues and cells. f. When teaching a patient about the use of sunscreens that protect against exposure to both UVA and UVB rays, the nurse advises the patient to look for inclusion of benzophenones. Rationale: Obesity affects skin with increased sweating that causes inflammation and dry skin, poot wound healing, and problems in skin folds. Photosensitivity occurs when certain chemicals absorb light from the sun and harm the skin. Benzophenones block both UVA ad UVB rays. Vitamin A, not vitamin C, is critical in maintaining and repairing the structure of epithelial cells. Exposure of UVB rays, not UVA rays, is believed to be the most important factor in the development of skin cancer. Sunscreen, not topical hydrocortisone, can block the photosensitivity caused by various drugs.

What skin condition has hyperkeratotic, scaly lesion and is a precursor of squamous cell carcinoma, and is treated with topical fluorouracil (5-FU)? a. Actinic keratosis B. Basal cell carcinoma C. Malignant melanoma D. Squamous cell carcinoma

ANS: a. actinic keratosis Rationale: Basal cell carcinaoma is nodular and ulcerative with pearly borders. Actinic keratosis is the most common premalignant skin lesion. Malignant melanoma is the deadliest skin cancer and has increased risk in people with dysplastic nervus syndrome. SCC is a malignant neoplasm of keratinizing epidermal cells.

What is the most common diagnostic test used to determine a causative agent of skin infections? a. Culture b. Tzanck test c. Immunofluorescent studies d. Potassium hydroxide (KOH) slides

ANS: a. culture Rationale: A culture can be performed to distinguish among fungal, bacterial, and viral infections. A Tzanck test is specific for herpesvirus infections, potassium hydroxide slides are specific for fungal infections, and immunofluorescent studies are specific for infections that cause abnormal antibody proteins.

A patient is scheduled for a hemorrhoidectomy at an ambulatory surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for a. diagnostic studies and peri-operative medications b. pre-op and post-op teaching by the nurse c. psychologic support to alleviate fears of pain and discomfort d. pre-op nursing assessment related to possible risks and complications

ANS: a. diagnostic studies and peri-op meds Rationale: ambulatory surgery is usually less expensive and more convenient, generally involving fewer lab tests, fewer pre/post op meds, less psychological stress, and less susceptibility to hospital acquired infections. However, the nurse is still responsible for assessing, supporting, and teaching the patient who is undergoing surgery, regardless of where the surgery is performed

What type of procedural info should be given to a patient in preparation for ambulatory surgery (SELECT ALL THAT APPLY) a. how pain will be controlled b. any fluid and food restrictions c. characteristics of monitoring equipment d. what odors and sensations may be experienced e. technique and practice of coughing and deep breathing, if appropriate

ANS: a. how pain will be controlled b. any fluid and food restrictions e. technique and practice of coughing and deep breathing, if appropriate Rationale: Procedural information includes what will or should be done for surgical prep, including what to bring and wear to surgery, length and type of food/fluid restrictions, physical prep required, pain control, need for coughing and deep breathing (if appropriate), and procedures done before and during surgery. The other options are sensory and process information

During a pre-op physical assessment, the nurse is alerted to the possibility of compromised respiratory function during or after surgery in a patient with which problem? a. obesity b. dehydration c. enlarged liver d. decreased peripheral pulses

ANS: a. obesity Rationale: as well as spinal, chest, and airway deformities, may compromise respiratory function during and after surgery. Dehydration may require pre-op fluid therapy and an enlarged liver may indicate hepatic dysfunction that will increase peri-op risk r/t glucose control, coagulation, amd drug interactions. Weak peripheral pulses may reflect circulatory problems that could affect healing

During the healing phase of inflammation, which cells would be mostly likely to regenerate? a. Skin b. Neurons c. Cardiac muscle d. Skeletal muscle

ANS: a. skin Rationale: Labile cells of the skin, lymphoid organs, bone marrow, and mucous membranes divide constantly and regenerate rapidly following injury. Stable cells, such as those in bone, liver, pancreas, and kidney, regenerate slowly only if they are injured. Axons in the CNS are generally less successful at regeneration than peripheral axons. There may be a certain amount of recovery after injury involving the neurons. Cardiac muscle is not expected to regenerate but will scar when damaged.

A patient had abdominal surgery 3 months ago and calls the clinic with complaints of severe abdominal pain and cramping, vomiting, and bloating. What should the nurse most likely suspect as the cause of the patient's problem? a. Infection b. Adhesion c. Contracture d. Evisceration

ANS: b. Adhesion Rationale: Adhesion is a band of scar tissue that forms between organs. It may occur in the abdominal cavity and cause intestinal obstruction. Infection could be seen with undernutrition or necrotic tissue but would not cause these symptoms. Contractures shorten the muscle or scar tissue but would not contribute to abdominal symptoms. Evisceration of an abdominal would would occur sooner after surgery when the wound edges separate and the intestines protrude through the wound.

The patient asks the nurse what telangiectasia looks like. Which is the best description for the nurse to give the patient? a. A circumscribed, flat discoloration b. Small, superficial, dilated blood vessels c. Benign tumor of blood or lymph vessels d. Tiny purple spots resulting from tiny hemorrhages

ANS: b. Small, superficial, dilated blood vessels Rationale: Telangiectasia looks like small, superficial, dilated blood vessels. A small circumscribed, flat discoloration describes a macule. A benign tumor of blood or lymph vessels describes an angioma. Tiny purple spots resulting from tiny hemorrhages describes petechiae.

What is characteristic of chronic inflammation? a. It may last 2 to 3 weeks. b. The injurious agent persists or repeatedly injures tissue. c. Infective endocarditis is an example of chronic inflammation. d. Neutrophils are the predominant cell type at the site of inflammation.

ANS: b. The injurious agent persists or repeatedly injures tissue. Rationale: The injurious agent of chronic inflammation persists or repeatedly injures tissue. I lasts for weeks, months, or year. Infective endocarditis is a subacute inflammation that lasts for weeks or months. Neutrophils are the predominant cell type in acute inflammation. Lymphocytes and macrophages are the predominant cell types at chronic inflamation sites.

A home health nurse is visiting an older obese woman who has recently had hip surgery. She tells the patient's caregiver that the patient has intertrigo. When the caregiver asks what that is, the nurse should tell the caregiver that it is a. thickening of the skin. b. dermatitis in the folds of her skin. c. loss of color in diffuse areas of her skin. d. a firm plaque caused by fluid in the dermis.

ANS: b. dermatitis in the folds of her skin. Rationale: Intertrigo is dermatitis in the folds of her skin. Thickening of the skin is lichenification. Loss of color in diffuse areas of skin is vitiligo. A firm plaque caused by fluid in the dermis is a wheal.

An active athletic person calls the clinic and describes her feet as having linear breaks through the skin. What is the most likely diagnosis of this problem? a. Scales b. Fissure c. Pustule d. Comedo

ANS: b. fissure Rationale: Scales are excess dead epidermal cells. A pustule is a circumscribed collection of leukocytes and free fluid. Comedo is associated with acne vulgaris.

For which nursing diagnoses or collaborative problems common in post-op patients has ambulation been found to be an appropriate intervention (SELECT ALL THAT APPLY) a. impaired skin integrity r/t incision b. impaired mobility r/t decreased muscle strength c. risk for aspiration r/t decreased level of consciousness d. ineffective airway clearance r/t decreased respiratory excursion e. constipation r/t decreased physical activity and impaired GI motility f. venous thromboembolism r/t dehydration, immobility, vascular manipulation, or injury

ANS: b. impaired mobility r/t decreased muscle strengthd. ineffective airway clearance r/t decreased respiratory excursion e. constipation r/t decreased physical activity and impaired GI motility f. venous thromboembolism r/t dehydration, immobility, vascular manipulation, or injury Rationale: These problems are improved with ambulation. Other collaborative problems could be potential complications: urinary retention, atelectasis, and pneumonia.

The nurse observes that redness remains after palpation of a discolored lesion on the patient's leg. This finding is characteristic of: a. varicosities. b. intradermal bleeding. c. dilated blood vessels. d. erythematous lesions.

ANS: b. intradermal bleeding Rationale: Discolored lesions that are caused by intradermal or subcutaneous bleeding do not blanch with pressure, whereas those caused by inflammation and dilated blood vessels will blanch and refill after palpation. Varicosities are engorged, dilated veins that may empty with pressure applied along the vein.

A patient has a plaque lesion on the dorsal forearm. Which type of biopsy is most likely to be used for diagnosis of the lesion? a. Punch biopsy b. Shave biopsy c. Incisional biopsy d. Excisional biopsy

ANS: b. shave biopsy Rationale: A shave biopsy is done for superficial lesions that can be scraped with a razor blade, removing the full thickness of the stratum corneum. An excisional biopsy is done when the entire removal of a lesion is desired. Punch biopsies are done with larger nodules to examine for pathology, as are incisional biopsies.

Which description characterizes seborrheic keratosis? A. White patchy yeast infection B. Warty, irregular papules or plaques C. Excessive turnover of epithelial cells D. Deep inflammation of subcutaneous tissue

ANS: b. warty, irregular papules or plaques. Rationale: Seborrheic keratosis are irregularly round or oval shaped and are often verrucuos papules or plaques. Candidiasis a white patchy yeast infection. Cellulitis is a deep inflammation of subcutaneous tissue. Psoriasis is an excessive turnover of epithelial cells.

Which patient is at the greatest risk for developing pressure ulcers? a. A 42-year-old obese woman with type 2 diabetes b. A 78-year-old man who is confused and malnourished c. A 30-year-old man who is comatose following a head injury d. A 65-year-old woman who has urge and stress incontinence

ANS: c. A 30-year-old man who is comatose following a head injury Rationale: The immobility, mental deterioration, and possible neurologic disorder of teh comatose patient present the greatest risk for tissue damage related to pressure. His Braden score is 9, which puts him at a very high risk. Although obesity, hyperglycemia, advanced age, mental deterioration, malnutrition, and incontinence contribute to development of pressure ulcers, the risk is not as high for any of the other patients.

What does the mechanism of chemotaxis accomplish? a. Causes the transformation of monocytes into macrophages b. Involves a pathway of chemical processes resulting in cellular lysis c. Attracts the accumulation of neutrophils and monocytes to an area of injury d. Slows the blood flow in a damaged area, allowing migration of leukocytes into tissue

ANS: c. Attracts the accumulation of neutrophils and monocytes to an area of injury Rationale: Chemotaxis involves the release of chemicals at the site of tissue injury. When monocytes move from the blood into tissue, they are transformed into macrophages. The complement system is a pathway of chemical processes that results in cellular lysis, vasodilation, and increaed capillary permeability causing the slowing of blood flow to the area. Prostaglandins slow blood flow to allow for cot formation at the injury

A patient's documentation indicates he has a stage III pressure ulcer on his right hip. What should the nurse expect to find on assessment of the patient's right hip? a. Exposed bone, tendon, or muscle b. An abrasion, blister, or shallow crater c. Deep crater through subcutaneous tissue to fascia d. Persistent redness (or bluish color in darker skin tones)

ANS: c. Deep crater through subcutaneous tissue to fascia Rationale: Stage III is full-thickness tissue loss; subcutaneous fat may be visible. Bone, tendon, and muscle are exposed in a stage IV pressure ulcer. Abraison, blister, and shallow crater are seen in stage II pressure ulcers. Persistent redness or discoloration of darker skin tones describes a stage I pressure ulcer.

What is the primary difference between healing by primary intention and healing by secondary intention? a. Primary healing requires surgical debridement for healing to occur. b. Primary healing involves suturing two layers of granulation tissue together. c. Presence of more granulation tissue in secondary healing results in larger scar. d. Healing by secondary intention takes longer because more steps in the healing process are necessary.

ANS: c. Presence of more granulation tissue in secondary healing results in larger scar. Rationale: The process of healing by secondary intention is essentially the same as primary healing. With the greater defect and gaping wound edges of an open wound, healing and granulation take place from the edges inward and from the bottom of the wound up, resulting in more granulation tissue and a much larger scar. Secondary healing may require surgical debridement for healing to occur. In primary healing, the edges of the wound are aligned and may be sutured. Tertiary healing involves delayed suturing of two layers of granulation tissue together and may require debridement of necrotic tissue.

The patient is admitted from home with a clean stage II pressure ulcer. What does the nurse expeect to observe when she does her wound assessment? a. Adherent gray necrotic tissue b. Clean, moist granulating tissue c. Red-pink wound bed, without slough d. Creamy ivory to yellow-green exudate

ANS: c. Red-pink wound bed, without slough. Rationale: The stage II pressure ulcer is a shallow, partial thickness wound with a red-pink wound bed, without slough. Adherent gray necrotic tissue describes eschar tissue, which cannot be staged. Clean, moist granulating tissue occurs over time as the wound heals. Creamy exudate occurs when the wound is contaminated or infected, regardless of the stage of the pressure ulcer.

Priority Decision: What is the most important nursing intervention for the prevention and treatment of pressure ulcers? a. Using pressure-reduction devices b. Massaging pressure areas with lotion c. Repositioning the patient a minimum of every 2 hours d. Using lift sheets and trapeze bars to facilitate patient movement

ANS: c. Repositioning the patient a minimum of every 2 hours Rationale: Relief of pressure on tissues is critical to prevention and treatment of pressure ulcers. Although, pressure-reduction devices may relieve some pressure and lift sheets and trapeze bars prevent skin shear, they are no substitute for frequent repositioning individualized for the patient. Massage is contraindicated if there is the presence of acute inflammation or possibly damaged blodd vessels or fragile skin.

Which nutrients aid in capillary synthesis and collagen production by the fibroblasts in wound healing? a. Fats b. Proteins c. Vitamin C d. Vitamin A

ANS: c. Vitamin C Rationale: Vitamin C aids healing with capillary synthesis and collagen production by fibroblasts. Fats provide synthesis of fatty acids and triglycerides used for cellular membranes. Protein corrects negative nitrogen balance from increased metabolism and contributes to synthesis of immune factors, blood cells, fibroblats, and collagen. Vitamin A aids in epithelializaiton, increasing collagen synthesis, and tensile strength of the healing wound.

When the nurse asks a pre-op patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next? a. note this information in the patient's record as hay fever and food allergies b. place an allergy alert wristband that ID's the specific allergies on the patient c. ask the patient to describe the nature and severity of any allergic responses experienced from these agents d. notify the anesthesia care provider because the patient may have an increased risk for allergies to anesthetics

ANS: c. ask the patient to describe the nature and severity of any allergic responses experienced from these agents Rationale: risk factors for latex allergies include a history of hay fever and allergies to foods such as avocados, kiwi, bananas, potatoes, peaches, and apricots. When a patient identifies with such allergies, the patient should be further questioned about exposure to latex and specific reactions to allergens. A history of any allergic responsiveness increases the risk for hypersensitivity reactions to drugs and during anesthesia but the hay fever and fruit allergies are specifically r/t latex allergy. After IDing the allergic reaction, the ACP should be notified , the allergy alert wristband should be applied, and the note in the record will include the allergies and reactions as well as the nursing actions r/t the allergies

Chapter 22 When the nurse is assessing the skin of an older adult, which factor is likely to contribute to dry skin? a. Increased bruising b. Excess perspiration c. Decreased extracellular fluid d. Chronic ultraviolet light exposure

ANS: c. decreased extracellular fluid Rationale: In older adults the dermis loses volume and has fewer blood vessels, which contributes to decreased extracellular water. Some older people do not drink enough fluids and this can also contribute to dry skin. In older adults there are also decreased surface lipids and apocrine and sebaceous gland activity. Increased bruising from capillary fragility does not contribute to dry skin.

A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause? a. diuresis b. hyperkalemia c. fluid retention d. impaired blood coagulation

ANS: c. fluid retention Rationale: The stress response causes fluid retention during the first 1 to 3 days postoperatively and fluid overload is possible during this time. Fluid retention results from secretion and release of antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH) by the pituitary and activation of the renin-angiotensin-aldosterone system (RAAS). ACTH stimulates that adrenal cortex to secrete cortisol and aldosterone. The RAAS increases aldosterone release, which also increases fluid retention. Aldosterone causes renal potassium loss with possible hypokalemia and blood coagulation is enhanced by cortisol.

Which tubes drain gastric contents (SELECT ALL THAT APPLY)? a. T-tube b. hemovac c. nasogastric tube d. indwelling catheter e. gastrointestinal tube

ANS: c. nasogastric tube e. gastrointestinal tube Rationale: The nasogastric tube and gastrointestinal tube drain gastric contents. The T-tube drains bile, the Hemovac drains blood from the surgical site, and the indwelling catheter drains urine form the bladder.

What should be included in the instructions given to the post-op patient before discharge? a. need for follow-up care with home care nurses b. directions for maintaining routine post-op diet c. written information about self-care during recuperation d. need to restrict all activity until surgical healing is complete

ANS: c. written information about self-care during recuperation Rationale: All postoperative patients need discharge instructions regarding what to expect and what self-care can be assumed during recovery. Diet, activities, follow-up care, symptoms to report, and instructions about medications are individualized to the patient.

What is the primary difference between an excoriation and an ulcer? a. Ulcers do not penetrate below the epidermal junction. b. Excoriations involve only thinning of the epidermis and dermis. c. Excoriations will form crusts or scabs whereas ulcers remain open. d. An excoriation heals without scarring because the dermis is not involved.

ANS: d. An excoriation heals without scarring because the dermis is not involved. Rationale: An excoriation is a focal loss of epidermis; it does not involve the dermis and, as such, does not scar with healing. Ulcers do penetrate into and through the dermis and scarring does occur with these deeper lesions. Epidermal and dermal thinning is atrophy of the skin but does not involve a break in skin integrity. Both excoriations and ulcers have a break in skin integrity and may develop crusts or scabs over the lesions.

What role do the B-complex vitamins play in wound healing? a. Decrease metabolism b. Protect protein from being used for energy c. Provide metabolic energy for the inflammatory process d. Coenzymes for fat, protein, and carbohydrate metabolism

ANS: d. Coenzymes for fat, protein, and carbohydrate metabolism Rationale: The B-complex vitamins are necessary coenzymes for many metabolic reactions, including protein, fat, and carbohydrate metabolizm. Carbohydrates provide metabolic energy for inflammation and are protein sparing. Fluid is needed to replace that used in exudates as well as the extra fluid used for the increased metabolic rate required for healing.

A patient had a complicated vaginal hysterectomy. The student nurse provided perineal care after the patient had a bowel movement. The student nurse tells the nurse there was a lot of light brown, smelly drainage seeping from the perianal area. What should the nurse suspect when assessing this patient? a. Dehiscence b. Hemorrhage c. Keloid formation d. Fistula formation

ANS: d. Fistula formation Rationale: A fistula is an abnormal passage between organs or between a hollow organ and skin that will leak fluid or pus until it is healed. In this situation there may be a fistula between the vagina and rectum. The student nurse did not describe dehiscence, hemorrhage, or keloid scar formation.

Priority Decision: During care of patients, what is the most important precaution for preventing transmission of infections? a. Wearing face and eye protection during routine daily care of the patient b. Wearing nonsterile gloves when in contact with body fluids, excretions, and contaminated items c. Wearing a gown to protect the skin and clothing during patient care activities likely to soil clothing d. Hand washing after touching fluids and secretions and removing gloves, as well as between patient contacts

ANS: d. Hand washing after touching fluids and secretions and removing gloves, as well as between patient contacts Rationale: Hand washing is the most important factor in preventing infection transmission and is recommended before and after the use of gloves by the Centers for Disease Control and Prevention for all types of isolation precautions in health care facilities.

What effect does the action of the complement system have on inflammation? a. Modifies the inflammatory response to prevent stimulation of pain b. Increases body temperature, resulting in destruction of microorganisms c. Produces prostaglandins and leukotrienes that increase blood flow, edema, and pain d. Increases inflammatory responses of vascular permeability, chemotaxis, and phagocytosis

ANS: d. Increases inflammatory responses of vascular permeability, chemotaxis, and phagocytosis Rationale: The processes that are stimulated by the activation of the complement system include enhanced phagocytosis, increased vascular permeability, chemotaxis, and cellular lysis. Prostaglandins and leukotrienes are released by damaged cells, and body temperature is increaed by the action of prostaglandins and interleukins. All chemical mediators of inflammation increase the inflammatory response and, as a result, increase pain.

Which nursing interventions for a patient with a Stage IV sacral pressure ulcer are mostappropriate to assign or delegate to a licensed practical nurse (LPN) (select all that apply)? a. Assess and document wound appearance. b. Teach the patient pressure ulcer risk factors. c. Choose the type of dressing to apply to the ulcer. d. Measure the size (width, length, depth) of the ulcer. e. Assist the patient to change positions at frequent intervals.

ANS: d. Measure the size (width, length, depth) of the ulcer. e. Assist the patient to change positions at frequent intervals. Rationale: Measuring the size of the wound and repositioning do not require judgement, patient teaching, or evaluation of care. The other interventions listed relate to assessment, judgement, and teaching, all of which are responsibilities of the RN. However, the LPN can reinforce teaching by the RN. The unlicensed assistive personnel may also be able to help with repositioning, if delegated by the RN.

What is the name for papillomavirus infection seen on the skin? A. Furuncle B. Carbuncle C. Erysipelas D. Plantar wart

ANS: d. plantar wart Rationale: A plantar wart is caused by (HPV). A furuncle is a deep skin infection with staphylococci around the hair follicle. A carbuncle is multiple, interconnecting furuncles. Erysipelas is superficial cellulitis primarily involving the dermis.

To prevent airway obstruction in the post-op patient who is unconscious or semiconscious, what will the nurse do? a. encourage deep breathing b. elevate the head of the bed c.administer oxygen per mask d. position the patient in a side-lying position

ANS: d. position the patient in a side-lying position Rationale: An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used but the patient must first have a patent airway.

When obtaining important health information from a patient during assessment of the skin, it is important for the nurse to ask about a. a history of freckles as a child. b. patterns of weight gain and loss. c. communicable childhood illnesses. d. skin problems related to the use of medications.

ANS: d. skin problems related to the use of medications. Rationale: A careful medication history is important because many medications cause dermatologic side effects and patients also use many over-the-counter preparations to treat skin problems. Freckles are common in childhood and are not related to skin disease. Communicable childhood illnesses are not directly related to skin problems, although varicella viruses may affect the skin in adulthood. Patterns of weight gain and loss are not significant but the presence of obesity may cause skin problems in overlapping skin areas.

A 66-year-old African American patient is scheduled to have a basal cell carcinoma on his cheeck excised in his HCP's office. What discharge teaching is most important for the nurse to include for this patient? a. you will probably need radiation as well after the excision. b. it is good you are having it removed to avoid massive tissue destruction c. it is too bad you can't have this done by laser because it leaves less scarring d. using the prescribed ointment and an adhesive bandage will promote the healing with less scarring.

ANS: d. using the prescribed ointment and an adhesive bandage will promote the healing with less scarring Rationale: Using the prescribed ointment to keep the wound moist and the bandage for protection will promote healing and less scarring. Radiation is not used after excision of BCC. Without treatment, BCC causes massive tissue destruction, but he has it treated. Laser surgery is not used for BCC, so this is not appropriate. The potential of keloid scarring may be included for this African American patient.

Number the following actions in the order they should be done in the emergency management of a burn of any type, beginning with number one for the first action: a. establish and maintain an airway b. assess for other associated injuries c. establish an IV line with a large-gauge needle d. remove the patient from the burn source and stop the burning process

ANS: 2, 4, 3, 1 Rationale: The first intervention in emergency management of a burn injury is to remove the burn source and stop the burning process. Airway maintenance would be second, then establishing IV access, followed by assessing for other injuries.

The nurse has received the change-of-shift report on his group of patients. Indicate the priority order in which the nurse should see these patients. a. A 40 yr old female who is returning from the postanesthesia care unit (PACU) following surgical debridement of her back and legs. b. A 76 yr old male with parital-thickness burns of his arms and abdomen who is complaining of severe pain. c. a 62 yr old female who was just admitted following partial-thickness burns to her anterior chest, face, and neck. d. An 18 yr old male with full-thickness burns of his lower extremities who is refusing to go for his scheduled dressing change.

ANS: 3, 2, 1, 4 Rationale: Face and neck burns are frequently associated with airway inhalation. Therefore this patient requires airway assessment (priority= ABC's). Severe pain would be the next priority (high physiologic need). The patient returning from the PACU will need to be seen soon to assess vital signs, level of consciousness, IV fluids, and wounds. However, at the current time the transport personnel should be with her. The 18-yr-old is not at risk related to ABCs, and it will probably take a few minutes to talk with him about why he does not want to go for the dressing change.

A female patient with chronic skin lesions of the face and arms tells the nurse that she cannot stand to look at herself in the mirror anymore because of her appearance. Based on this information, the nurse identifies which nursing diagnosis. A. Anxiety related to personal appearance B. Disturbed body image related to perception of unsightly lesions C. Social isolation related to decreased activities a s a result of poor self-image D. Ineffective self-health management related to lack of knowledge of cover-up techniques

ANS: B. Disturbed body image related to perception of unsightly lesions Rationale: Defining characteristics for body image problems include verbalization of self-disgust and reluctance to look at lesions, as evidenced in this patient. Social isolation is indicated only if there is evidence of decreases social activities and of anxiety by verbalization of anxiety and frustration. Although, ineffective health management may be a problem, it is not indicated in this situation.

The nurse plans care for a patient with a newly diagnosed malignant melanoma based on the knowledge that initial treatment may involve (select all that apply) A. Shave biopsy B. Moh's surgery C. Surgical excision D. Localized radiation E. Fluorouracil (5-FU) F. Topical nitrogen mustard

ANS: B. Moh's surgery C. Surgical excision Rationale: In the early stages, surgical excision with a margin of normal skin is the initial treatment for malignant melanoma. Mohs' surgery can also be used to treat malignant melanoma. Radiation may be used after excision for malignant melanoma, depending on staging of the disease. A shave biopsy is used for diagnosis, not treatment. Topical nitrogen mustard may be used for treatment of cutaneous T-cell lymphoma. Fluorouracil is used to treat actinic keratosis.

Which skin conditions are more common in immunosuppressed patients (select all that apply)? A. Acne B. Lentigo C. Candidiasis D. Herpes Zoster E. Herpes simplex 1 F. Kaposi sarcoma

ANS: C. Candidiasis E. Herpes simplex 1 F. Kaposi sarcoma Rationale: Patients who are immunocompromised are at an increased risk for candidiasis (a fungal infection), herpes simplex 1 (caused by a virus), and Kaposi sarcoma(vascular lesions on the skin, mucous membranes, and viscera with wide range presentation). The other options are not at increased risk with immunosuppression. Acne is caused by inflammation of sebaceous glands. lentigo (also called "liver spots" or "age spots") is caused by increased number of normal melanocytes in the basal layer of epidermis. Hepres zoster virus, which is a group of vesicles and pustules resembling chickenpox located in linear distribution along dermatome.

What type of dressing will the nurse most likely use for the patient in the question before? a. Hydrocolloid b. Transparent film c. Absorptive dressing d. Negative pressure wound therapy

ANS: a. Hydrocolloid Rationale: A clean wound would be treated with a hydrocolloid or hydrogel dressing because they provide a moist environment to encourage granulation. Transparent film would be likely to result in further tissue loss. There would not be enough drainage for an absorptive dressing unless this pressure ulcer became infected. An eschar wound may be treated with autolytic debridement and than negative pressure wound therapy, depending on depth and healing of the wound.

A patient with deep partial-thickness burns over 45% of his trunk and legs is going for debridement in the cart shower 48 hours post burn. what is the drug of choice to control the patient's pain during this activity? a. IV morphine b. midazolam (versed) c. IM meperidine (demerol) d. long-acting oral morphine

ANS: a. IV morphine Rationale: Morphine is the drug of choice for pain control, and during the emergent phase it should be administered IV because GI function is impaired and IM injections will not be absorbed adequately. Amnesia from midazolam is not needed for pain control.

The patient has diabetes mellitus and COPD that has been treated with high-dose corticosteroids for the past several years. Which dermatologic manifestations could be related to these systemic problems (select all that apply)? A. Acne B. Increased sweating C. Dry, coarse, brittle hair D. Impaired wound healing E. Erythematous plaques of the shins F. Decreased subcutaneous fat over extremities

ANS: a. acne d. impaired wound healing e. Erythematous plaques of the shins f. Decreased subcutaneous fat over extremtiies. Rationale: Corticosteroid excess can cause acne and decreased subcutaneous fat over the extremities. Diabetes mellitus can cause erythematous plaques of the shins and and both the corticosteroids and diabetes can impair or delay wound healing. Increased sweating is seen with hyperthyroidism and coarse, brittle hair is seen with hypothyroidism.

What is the primary advantage of the use of midazolam (versed) as an adjunct to general anesthesia? a. amnestic effect b. analgesic effect c. prolonged action d. antiemetic effect

ANS: a. amnestic effect Rationale: Midazolam (Versed) is a rapid, short-acting, sedative-hypnotic benzodiazepine that is used to prevent recall of events under anesthesia because of its amnestic properties.

A patient who is being admitted to the surgical unit for a hysterectomy paces the floor, repeatedly saying, "I just want this over." What should the nurse do to promote a positive surgical outcome for the patient? a. ask the patient what her specific concerns are about the surgery b. redirect the patient's attention to the necessary pre-op preparations. c. reassure the patient that the surgery will be over soon and she will be fine. d. tell the patient she should not be so anxious because she is having a common, safe surgery

ANS: a. ask the patient what her specific concerns are about the surgery Rationale: excessive anxiety and stress can affect surgical recovery and the nurse's role in psychologically preparing the patient for surgery is to assess for potential stressors that could negatively affect surgery. Specific fears should be identified and addressed by the nurse by listening and explaining planned post-op care. Falsely reassuring the patient, ignoring her behavior, and telling her not to be anxious are not therapeutic

What is the primary goal of the circulating nurse during preparation of the operating room, transferring and positioning patient, and assisting the anesthesia team? a. avoiding any type of injury to the patient b. maintaining a clean environment for the patient c. providing for patient comfort and sense of well-being d. preventing breaks in aseptic technique by the sterile members of the team

ANS: a. avoiding any type of injury to the patient Rationale: The protection of the patient from injury in the OR environment is maintained by the circulating nurse by ensuring functioning equipment, preventing falls and injury during transport and transfer, monitoring asepsis, and providing supportive care for the anesthetized patient

Chapter 19 What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on? a. condition of patient b. type of anesthesia used c. preference of surgeon d. type of surgical procedure

ANS: a. condition of patient Rationale: Although some surgical procedures and drug administration require more intensive postanesthesia care, how fast and through which levels of care patients are moved depend on the condition of the patient. A physiologically unstable outpatient may stay an extended time in Phase I, whereas a patient requiring hospitalization but who is stable and recovering may well be transferred quickly to an inpatient unit.

What are the most appropriate compresses to use to promote comfort for a patient with inflamed, pruritic dermatitis? A. Cool tap water dressings B. Cool acetic acid dressings C. Warm sterile saline dressings D. Warm potassium permanganate dressings

ANS: a. cool tap water dressings. Rationale: Compresses used to treat pruritic lesions should be cool to cause vasoconstriction and to have an anti-inflammatory effect. Water is most commonly used and it does not need to be sterile. Acetic acid solutions are bactericidal and are used to treat skin infections. Potassium permanganate compresses are questionable.

The nurse is preparing a patient for transport to the OR. the patient is scheduled for a right knee arthoscopy. What actions should the nurse take at this time (SELECT ALL THAT APPLY)? a. ensure that the patient has voided b. verify that the informed consent is signed c. complete pre-op nursing documentation d. verify that the right knee is marked with indelible marker e. ensure that the H&P, diagnostic reports, and vital signs are on the chart

ANS: a. ensure that the patient has voided b. verify that the informed consent is signed c. complete pre-op nursing documentation d. verify that the right knee is marked with indelible marker e. ensure that the H&P, diagnostic reports, and vital signs are on the chart Rationale: all of these actions are needed to ensure that the pt is ready for surgery. in addition, the nurse should verify that the identification band and allergy band (if applicable) are on; the pt is not wearing any cosmetics; nail polish has been removed; valuables have been removed and secured; and prosthetics, such as eyeglasses, have been removed and secured

Many herbal products that are commonly taken cause surgical problems. Which herbs listed below should the nurse teach the patient to avoid before surgery to prevent an increase in bleeding for the surgical patient (SELECT ALL THAT APPLY)? a. garlic b. fish oil c. valerian d. vitamin e e. astragalus f. ginko biloba

ANS: a. garlic b. fish oil d. vitamin e f. ginko biloba Rationale: valerian may cause excess sedation; astragalus may increase blood pressure before and during surgery

The patient is visiting the free clinic to refill her medications. During the generalized assessment, the nurse documents alopecia; an increased heart rate; warm, moist, flushed skin; and thin nails. The patient also states she is anxious and has lost weight lately. Which systemic problem will the nurse most likely suspect and relate to the health care provider? a. hyperthyroidism b. systemic lupus erythematosus c. Vitamin B1 (thiamine) deficiency d. Human immunodeficiency virus (HIV) infection.

ANS: a. hyperthyroidism Rationale: These manifestations are all present with hyperthyroidism related to accelerated body processes. Alopecia, fatigue, and photosensitivity are seen with systemic lupus erythematosus. Tachycardia, redness of the soles of the feet, and edema are seen iwth vitamin B1 (thiamine) deficiency. HIV infection would more likely manifest as Kaposi sarcoma or eosinophilic folliculitis.

With what are the post-op respiratory complications of atelectasis and aspiration of gastric contents associated? a. hypoxemia b. hypercapnia c. hypoventilation d. airway obstruction

ANS: a. hypoxemia Rationale: Hypoxemia occurs with atelectasis and aspiration as well as pulmonary edema, pulmonary embolism, and bronchospasm. Hypercapnia is caused by decreased removal of CO2 from the respiratory system that could occur with airway obstruction or hypoventilation. Hyperventilation may occur with depression of central respiratory drive, poor respiratory muscle tone due to disease or anesthesia, mechanical restriction, or pain. Airway obstruction could occur with the tongue blocking the airway, restrained thick secretions, laryngospasm, or laryngeal edema.

A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient? a. hypoxemia b. neurologic injury c. distended bladder d. cardiac dysrhythmias

ANS: a. hypoxemia Rationale: The most common cause of emergence delirium is hypoxemia and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury and cardiac dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

What is the most common reason elective cosmetic surgery is requested by patients? A. Improve self-image B. Remove deep acne scars C. Lighten the skin in pigmentation problems D. Prevent skin changes associated with aging

ANS: a. improve self-image Rationale: Improvement of self-image is the most common reason for undergoing cosmetic surgery; appearance is an important part of confidence and self-assurance. Acne scars, pigmentation problems, and wrinkling can be treated with cosmetic surgery but the surgery does not prevent the skin changes associated with aging.

What is the initial cause of hypovolemia during the emergent phase of burn injury? a. increased capillary permeability b. loss of sodium to the interstitium c. decreased vascular oncotic pressure d. fluid loss from from denuded skin surfaces .

ANS: a. increased capillary permeability Rationale: Although all of the selections add to the hypovolemia that occurs in the emergent burn phase, the initial and most pronounced effect is caused by fluid shifts out of the blood vessels as a result of increased capillary permeability.

When assessing a patient's full-thickness burn injury during the emergent phase, what would the nurse expect to find? a. leathery, dry, hard skin b. red, fluid-filled vesicles c. massive edema at the injury site d. serous exudate on a shiny, dark brown wound

ANS: a. leathery, dry, hard skin Rationale: Dry, waxy white, leathery, or hard skin is characteristic of full-thickness burns in the emergent phase, and it may turn brown and dry in the acute phase. Deep partial-thickness burns in the emergent phase are red and shiny and have blisters. Edema may not be as extensive in full-thickness burns because of thrombosed vessels.

The burn patient has developed an increasing dread of painful dressing changes. what would be the most appropriate treatment to ask the health care provider to prescribe? a. midazolam to be used with morphine before dressing changes b. morphine in a dosage range so that more may be given before dressing changes c. buprenorphine to be administered with morphine before dressing changes d. patient-controlled analgesia so that the patient may have control of analgesic administration

ANS: a. midazolam to be used with morphine before dressing changes. Rationale: Midazolam is useful when patients' anticipation of the pain experience increases their pain because it causes a short-term memory loss and, if given before a dressing change, the patient will not recall the event. A dosage range of morphine is useful, as is patient-controlled analgesia, but seldom will these doses effectively relieve the discomfort of dressing changes. Buprenorphine is an opioid agonist/antagonist and cannot be used with other opioids.

A nurse caring for a disheveled patient with poor hygiene observes that the patient that small red lesions flush with the skin on the head and body. The patient complains of severe itching at the sites. For what should the nurse further assess the patient? A. Nits on the shaft of his head hair B. A history of sexually transmitted diseases. C. The presence of ticks attached to the scalp D. The presence of burrows in the interdigital webs

ANS: a. nits on the shaft of his head Rationale: Pediculosis (head lice and body lice) causes very small, red, noninflammatory lesions that progress to popular wheal-like lesions and cause severe itching. Lice live on the body as nits (tiny white eggs) that are firmly attached to hair shafts on the head and body. Burrows, especially in interdigital webs, are found with scabies. Sexually transmitted infections and ticks do not produce these manifestations.

The PACU nurse applies warm blankets to a post-op patient who is shivering and has a body temperature of 96 degrees Fahrenheit. What treatment also may be used to treat the patient? a. oxygen b. vasodilating drugs c. antidysrhythmic drugs d. analgesics or sedatives

ANS: a. oxygen Rationale: The most common cause of emergence delirium is hypoxemia and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury and cardiac dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

Which nursing actions are completed by the scrub nurse (SELECT ALL THAT APPLY) a. prepares instrument table b. documents intraoperative care c. remains in the sterile area d. checks mechanical and electrical equipment e. passes instruments to surgeon and assistants f. monitors blood and other fluid loss and urine output

ANS: a. prepares instrument table c. remains in the sterile area e. passes instruments to surgeon and assistants Rationale: The circulating nurse documents intraoperative care, checks mechanical and electrical equipment, and monitors blood and other fluid loss and urine output

During the rehabilitation phase of a burn injury what can control the contour of the scarring? a. pressure garments b. avoidance of sunlight c. splinting joints in extension d. application of emollient lotions

ANS: a. pressure garments Rationale: After wound healing, pressure garments help to keep scars flat and prevent elevation and enlargement about the original burn injury area. Avoidance of sunlight is necessary for at least 3 months to prevent hyperpigmentation and sunburn injury to healed burn areas. Water-based lotions and splinting are used to prevent contractures.

Which skin condition occurs as an allergic reaction to mite eggs? a. scabies b. impetigo c. follicultitis d. pediculosis

ANS: a. scabies Rationale: In scabies, mites penetrate the skin and deposits eggs. An allergic reaction can result from the presence of eggs, feces, and mite parts. Streptococci or staphylococci cause impetigo with vesiculopustular lesions that develop thick, honey-colored crust surrounded by erythema. Folliculitis is a small pustule at the hair follicle opening with minimal erythema caused by staphylococci. Pediculosis is lice.

What is a skin graft that is used to transfer skin and subcutaneous tissue to large areas of deep tissue destruction called? A. Skin flap B. Free graft C. Soft tissue extension D. Free graft with vascular anastomoses

ANS: a. skin flaps Rationale: Skin flaps as grafts include moving skin and subcutaneous tissue to another part of the body and are used to cover wounds with poor vascular beds, adding padding, and cover wounds over cartilage and bone. Free grafts transfer the epidermis and part or all of the dermis or include establishment of circulation as well. Soft tissue extension involves placement of an expander under the skin, which stretches the skin over time to provide extra skin to cover the desired area.

A patient is scheduled for hip replacement surgery in the early afternoon is NPO but receives and ingests a breakfast tray with clear liquids on the morning of surgery. What response does the nurse expect when the ACP is notified? a. Surgery will be done as scheduled b. surgery will be rescheduled for the following day c. surgery will be postponed for 8 hours after the fluid intake d. a NG tube will be inserted to remove the fluids from the stomach.

ANS: a. surgery will be done as scheduled Rationale: the pre-op fasting recommendations of the american society of anesthesiology indicated that clear liquids can be taken up to 2 hours before surgery for healthy patients undergoing elective procedures. There is evidence that longer fasting is not necessary

A break in sterile technique occurs during surgery when the scrub nurse touches a. the mask with sterile gloved hands b. sterile gloved hands to the gown at chest level c. the drape at the incision site with sterile gloved hands d. the lower arm to the instruments on the instrument tray

ANS: a. the mask with sterile gloved hands Rationale: The mask covering the face is not considered sterile and if in contact with sterile gloved hands, it contaminates the gloves. The gown at chest level and 2 inches above the elbows is considered sterile, as is the drape placed at the surgical area

To prevent lichenification related to chronic skin problems, what does the nurse encourage the patient to do? A. Use measures to control itching. B. Wear sterile gloves when touching the lesions. C. Use careful hand washing and safe disposal of soiled dressings. D. Use topical antibiotics with wet-to-dry dressings over the lesions.

ANS: a. use measures to control itching. Rationale: Lichenification is thickening of the skin caused by chronic scratching or rubbing and can be prevented by controlling itching. It is not an infection, nor is it contagious, as the other options indicate.

A woman calls the health clinic and describes a rash that she has over the abdomen and chest. She tells the nurse it has raised, fluid-filled, small blisters that are distinct. a. Identify the type of primary skin lesion described by this patient. b. What is the distribution terminology for these lesions? c. What additional information does the nurse need to document the critical components of these lesions?

ANS: a. vesicles; b. discrete, localized to the chest and abdomen. c. color, size, height, shape, odor, and configuration

The nurse initially suspects the possibility of sepsis in the burn patient based on what changes? a. vital signs b. urinary output c. gastrointestinal function d. burn wound appearance

ANS: a. vital signs Rationale: Early signs of sepsis include an elevated temperature and increased pulse and respiratory rate accompanied by decreased blood pressure and, later, decreased urine output and perhaps paralytic ileus. A burn wound may become locally infected without causing sepsis.

The nurse asks a pre-op patient to sign a surgical consent form as specified by the surgeon and then sign the form after the patient does so. By this action, what is the nurse doing? a. witnessing the patient's signature b. obtaining informed consent from the patient for the surgery c. verifying that the consent for surgery is truly voluntary and informed d. ensuring that the patient is mentally competent to sign the consent form

ANS: a. witnessing the patient's signature Rationale: witnessing the patient's signature the health care provider is ultimately responsible for obtaining informed consent. However, the nurse may be responsible for obtaining and witnessing the patient's signature. The nurse may be a patient advocate during the signing of the consent form, verifying the consent is voluntary and that the patient understands the implications of consent, but the primary legal action by the nurse is witnessing the patient's signature

During the early emergent phase of burn injury, the patient's laboratory results would most likely include: a. ↑ Hct ↓ serum albumin, ↓ serum Na, ↑ serum K. b. ↓ Hct, ↓ serum albumin, ↓ serum Na, ↓ serum K. c. ↓ Hct, ↑ serum albumin, ↑ serum Na, ↑ serum K. d. ↑ Hct, ↑ serum albumin, ↓ serum Na. ↓ serum K.

ANS: a. ↑ Hct ↓ serum albumin, ↓ serum Na, ↑ serum K. Rationale: With increased capillary permeability, water, sodium, and plasma proteins leave the plasma and move into the interstitial spaces, decreasing serum sodium and albumin. Serum potassium is elevated because inured cells and hemolyzed red blood cells (RBCs) release potassium from cells. An elevated hematocrit is caused by water loss into the interstitium, creating a hemoconcentration.

What is included in the routine assessment of the patient's cardiovascular function on admission to the PACU? a.monitoring arterial blood gases b. ECG monitoring c. determining fluid and electrolyte status d. direct arterial blood pressure monitoring

ANS: b. ECG monitoring Rationale: ECG monitoring is performed on patients to assess initial cardiovascular problems during anesthesia recovery. Fluid and electrolyte status is an indication of renal function and determinations of arterial blood gases and direct arterial blood pressure monitoring are used only in special cardiovascular or respiratory problems.

What is the rationale for using pre-op checklists on the day of surgery? a. the patient is correctly identified and preoperative medications administered b. all pre-op orders and procedures have been carried out and documented c. voiding is the last procedure before the the patient is transported to the OR d. patients' families have been informed as to where they can accompany and wait for patients

ANS: b. all pre-op orders and procedures have been carried out and documented Rationale: pre-op checklists are a tool used to ensure that the many preparations and precautions performed before surgery have been completed and documented. Patient ID, instructions to the family, and administeration of pre-op meds are often documented on the checklist, which ensures no details are omitted

Because of the rapid elimination of volatile liquids used for general anesthesia, what should the nurse anticipate the patient will need early in the anesthesia recovery period? a. warm blankets b. analgesic meds c. observation for respiratory depression d. airway protection in anticipation of vomiting

ANS: b. analgesic meds Rationale: The volatile liquid inhalation agents have very little residual analgesia and patients experience early onset of pain when the agents are discontinued. These agents are associated with a low incidence of nausea and vomiting. Prolonged respiratory depression is not common because of their rapid elimination. Hypothermia is not related to use of these agents but they may precipitate malignant hyperthermia in conjunction with neuromuscular blocking agents.

What should the nurse include in the instructions for a patient with urticarial? A. Apply topical benzene hexachloride. B. Avoid contact with the causative agent. C. Gradually expose the area to increasing amounts of sunlight D. Use over-the-counter antihistamines routinely to prevent the condition.

ANS: b. avoid contact with the causative agent. Rationale: Uticaria is inflammation and edema in the upper dermis, most commonly caused by histamine released during an antibody-allergen reaction. The best treatment for all types of allergic dermatitis is avoidance of the allergen. Sunlight and warmth would increase the edema and inflammation. Antihistamines may be used for an acute outbreak but not to prevent the dermatitis.

What is the most common skin cancer and causes pearly borders? A. Actinic keratosis B. Basal cell carcinoma C. Malignant melanoma D. Squamous cell carcinoma

ANS: b. basal cell carcinoma Rationale: Basal cell carcinoma (BCC) is the most common skin cancer and has pearly borders. Actinic keratosis is an irregularly shaped, flat, slightly erythematous papule with indistinct borders and an overlying hard keratotic scale or horn. Malignant melanoma tumors arise in melanocytes. Malignant melanoma is the deadliest skin cancer and has an increased risk in people with dysplastic nevus syndrome. Squamous cell carcinoma is a malignant neoplasm of keratinizing epidermal cells.

Identify the factors that increase nutritional needs of the patient during the emergent and acute phases of burn injury: a. electrolyte imbalance b. core temp elevation c. calories and protein are used for tissue repair d. hypometabolic state secondary to decreased GI function e. massive catabolism characterized by protein breakdown and increased gluconeogenesis

ANS: b. core temp elevation c. calories and protein are used for tissue repair e. massive catabolism characterized by protein breakdown and increased gluconeogenesis Rationale: There is a hypermetabolic state proportional to the size of the burn, which increases the core temperature. Massive catabolism can occur and leads to malnutrition and delayed healing without adequate calorie and protein supplementation. The electrolyte imbalance has more effect on the fluid resuscitation than the nutritional needs.

Chapter 24 Which type of burn injury would cause myoglobinuria, long bone fractures, and cardiac dysrhythmias and/or cardiac arrest? a. thermal b. electrical c. chemical d. smoke and inhalation

ANS: b. electrical Rationale: An electrical injury causes tissue damage from intense heat generated by the electrical current passing through tissue, including muscle contractions that can fracture long bones and vertebrae. Myoglobin is released into the circulation when massive muscle damage occurs. The electric shock can even cause cardiac standstill or dysrhythmias as well as delayed dysrhythmias during the first 24 hours after injury.

The patient was admitted to the burn center with a full-thickness burn 42 hours after the thermal burn occurred. the nurse will apply actions related to which phase of burn management for this patient's care? a. acute b. emergent c. postacute d. rehabilitative

ANS: b. emergent Rationale: The emergent phase usually lasts up to 72 hours after the time the burn occurred and focuses on fluid resuscitation. The acute phase is after the emergent phase and may last weeks to months after the burn occurred but begins when the extracellular fluid is mobilized and diuresis occurs. There is no postacute phase. The rehabilitative phase begins weeks to months after the injury, when the wounds have healed and the patient participates in self-care.

When transporting an inpatient to the surgical department, a nurse from another area of the hospital is able to access which area? a. sterile core b. holding area c. corridors of surgical suite d. unprepared operating room

ANS: b. holding area Rationale: Persons in street clothes or attire other than surgical scrub clothing can interact with personnel of the surgical suite in unrestricted areas, such as the holding area, nursing station, control desk, or locker rooms. Only authorized personnel in surgical attire and hair covering are allowed in semirestricted areas, such as corridors, and masks must be worn in restriced areas, such as OR, clean core, and scrub sinks

What condition should the nurse anticipate that might occur during epidural and spinal anesthesia? a. spinal headache b. hypotension and bradycardia c. loss of consciousness and seizures d. downward extension of nerve block

ANS: b. hypotension and bradycardia Rationale: During epidural and spinal anesthesia, a sympathetic nervous system blockade may occur that results in hypotension, bradycardia, and nausea and vomiting. A spinal headache may occur after, not during, spinal anesthesia and loss of consciousness and seizures are indicative of IV absorption overdose. Upward extension of the effect of the anesthesia results in inadequate respiratory excursion and apnea.

The nurse assess that bowel sounds are absent and abdominal distention is present in a patient 12 hours post burn. the nurse notifies the health care provider and anticipates doing which action: a. withhold all oral intake except water b. insert a nasogastric tube for decompression c. administer a H2-histamine blocker such as cimetidine d. administer nutritional supplements through a feeding tube placed in the duodenum

ANS: b. insert a NG tube for decompression Rationale: The patient with large burns often develops paralytic ileus within few hours, and a NG tube is inserted and connected to low, intermittent suction. After GI function returns, feeding tubes may be used for nutritional supplementation, and H2 histamine blockers may be used to prevent Curling's ulcers. Free water is not given to drink because of the potential for water intoxication.

Chapter 18- What is the physical environment of a surgery suite primarily designed to promote? a. electrical safety b. medical and surgical asepsis c. comfort and privacy of the patient d. communication among the surgical team

ANS: b. medical and surgical asepsis Rationale: Although all of the factors listed are important to the safety and well-being of the patient, the first consideration in the physical environment of the surgical suite is prevention of transmission of infection to the patient

A burn patient has a nursing diagnosis of impaired physical mobility related to a limited range of motion resulting from pain. what is an appropriate nursing intervention for this patient? a. have the patient perform ROM exercises when pain is not present b. provide analagesic medications before physical activity and exercise c. teach the patient the importance of exercise to prevent contractures d. arrange for the physical therapist to encourage exercise during hydrotherapy

ANS: b. provide analgesic medications before physical activity and exercise. Rationale: The limited ROM in this situation is related to the patient's inability or reluctance to exercise the joints because of pain and the appropriate intervention is to help control the pain so that exercises can be performed. The patient is probably never without some pain. Teaching about prevention of contractures with exercise and enlisting the help of the physical therapist are important, but neither of these interventions addresses the cause.

What is one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full-thickness burn over the lower half of the body? a. fever b. shivering c. severe pain d. unconsciousness

ANS: b. shivering Rationale: Shivering often occurs in a patient with a burn as a result of chilling that is caused by heat loss, anxiety, or pain. Fever is a sign of infection in later burn phases. Severe pain is not common in full-thickness burns, nor is unconsciousness unless other factors are present.

A pre-op patient reveals that an uncle died during surgery because of a fever and cardiac arrest. Knowing the patient is at risk for malignant hyperthermia, the pre-op nurse alerts the surgical team. What is likely to happen next? a. the surgery will have to be canceled b. specific precautions can be taken to safely anesthetize the patient c. dantrolene (dantrium) must be given to prevent hyperthermia during surgery d. the patient should be placed on a cooling blanket during the surgical procedure

ANS: b. specific precautions can be taken to safely anesthetize the patient Rationale: Although malignant hyperthermia can result in cardiac arrest and dealth, if the patient is known or suspected to be at risk for the disorder, appropriate precautions taken by the ACP can provide a safe anesthesia for the patient. Because preventive measure are possible if the risk is known, it is critical that preoperative assessment include a careful family history of surgical events. Dantrolene (Dantrium) is given as a treatment for malignant hyperthermia, not as a preventive measure. The cooling blanket would have no effect.

What is an appropriate intervention to promote debridement and removal of scales and crusts of skin lesions? A. Warm oatmeal baths B. Warm saline dressings C. Cool sodium bicarbonate baths D. Cool magnesium sulfate dressings

ANS: b. warm saline dressings Rationale: Tepid or warm solutions should be used when the purpose is debridement and saline is a common debridement solution. Warm baths of oatmeal and sodium bicarbonate are used for itching of large areas of the body. Magnesium sulfate is used in baths or compresses for inflammation.

A patient's deep partial-thickness burns are treated with the open method. what should the nurse do when caring for the patient? a. ensure that sterile water is used in the debridement tank b. wear a cap, mask, gown, and gloves during patient contact c. use sterile gloves to remove the dressings and wash the wounds d. apply topical antimicrobial ointment with clean gloves to prevent wound trauma

ANS: b. wear a cap, mask, gown, and gloves during patient contact. Rationale: When a patient's wounds are exposed with the open method, the staff must wear caps, masks, gowns, and gloves. Sterile water is not necessary in the debridement tank. If dressings are used with the open method, they are removed and wounds are washed with clean gloves. Topical anti-infective agents should be applied with sterile gloves to prevent infection.

Priority Decision: A patient is receiving chemotherapy. She calls the physician's office and says she is experiencing itching in her groin and under her breasts. What is the first nursing assessment that would be done before the nurse makes an appointment for the patient with the physician to determine the treatment? A. Her height and weight B. What the areas look like C. If chemotherapy was completed D. Culture and sensitivity of the areas

ANS: b. what the area looks like Rationale: The appearance of candidiasis on the skin shows diffuse popular erythematous rash with pinpoint satellites around the affected area. Height and weight could show if the patient is obese but it would be better to ask if the areas affected are moist. The chemotherapy could contribute to candidiasis but it does not matter if the chemotherapy treatments are finished. Culture and sensitivity of the area may be ordered by the physician at the patient's appointment.

To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations? a. when the patient is awake b. when the patient first arrives in the PACU c. when the patient becomes frightened or agitated d. when the patient can be aroused and recognizes where he or she is

ANS: b. when the patient first arrives in the PACU Rationale: Even before patients awaken from anesthesia, their sense of hearing returns and all activities should be explained by the nurse from the time of admission to the PACU to assist in orientation and decrease confusion.

Priority Decision: Key interventions for treating soft tissue injury and resulting inflammation are remembered using the acronym RICE. What are the most important actions for the emergency department nurse to do for the patient with an ankle injury? a. Reduce swelling, shine light on wound, control mobility, and elicit the history of the injury b. Rub the wound clean, immobilize the area, cover the area protectively, and exercise that leg c. Rest with immobility, apply a cold compress, apply a compress bandage, and elevate the ankle d. Rinse the wounded ankle, image the ankle, carry the patient, and extend the ankle with imaging

ANS: c. Rest with immobility, apply a cold compress, apply a compress bandage, and elevate the ankle Rationale: The nurse will encourage Rest and Immobility to prevent further injury. Ice or cold Compresses will be applied to decrease swelling with vasoconstriction. Compression will help to reduce edema and stop bleeding if it is occuring. Elevation will help to decrease edema and pain. The other options are not correct.

The patient's wound is not healing, so the health care provider is going to send the patient home with negative pressure wound therapy or a "wound vac" device. What will the caregiver need to understand about the use of this device? a. The wound must be cleaned daily. b. The patient will be placed in a hyperbaric chamber. c. The occlusive dressing must be sealed tightly to the skin. d. The diet will not be as important with this sort of treatment.

ANS: c. The occlusive dressing must be sealed tightly to the skin. Rationale: For the negative pressure therapy to work, a vacuum is created between the device and the wound so that the excess fluid, bacteria, and debris are removed from the wound. The wound is cleaned weekly or when the dressing is replaced. A hyperbaric oxyfen therapy chamber is not used with a negative pressure device. Nutrition must be maintained, as protein and electrolytes may be removed from the wound.

While assessing a patient in the PACU, the nurse finds that the patient's blood pressure is below the pre-op baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed? a. a urinary output >30 mL/hr b. an oxygen saturation of 88% c. a normal pulse with warm, dry, pink skin d. a narrowing pulse pressure with normal pulse

ANS: c. a normal pulse with warm, dry, pink skin Rationale: Hypotension with normal pulse and skin assessment is typical of residual vasodilating effects of anesthesia and requires continued observation. An oxygen saturation of 88% indicates hypoxemia, whereas a narrowing pulse pressure accompanies hypoperfusion. A urinary output >30 mL/hr is desirable and indicates normal renal function.

How is the initial information given to the PACU nurses about the surgical patient? a. a copy of the written operative report b. a verbal report from the circulating nurse c. a verbal report from the ACP d. an explanation of the surgical procedure from the surgeon

ANS: c. a verbal report from the ACP Rationale: The admission of the patient to the PACU is a joint effort between the ACP, who is responsible for supervising the postanesthesia recovery of the patient, and the PACU nurse, who provides care during anesthesia recovery. The ACP gives a verbal report that presents the details of the surgical and anesthetic course, preoperative conditions influencing the surgical and anesthetic outcome, and PACU treatment plans to ensure patient safety and continuity of care.

When assessing an African American patient, the nurse notes ashen color of the nail beds. What should the nurse do next? a. palpate for rashes on the legs. b. assess for jaundice in the sclera of the eye c. assess the mucous membranes of cyanosis d. assess for pallor of the skin on the buttocks

ANS: c. assess the mucous membranes of cyanosis Rationale: In dark-skinned individuals, cyanosis is seen as ashen nail beds, conjunctiva, or mucous membranes. Vital signs, lung sounds, and cardiorespiratory history would be assessed after verifying cyanosis of mucous membranes. Palpating for rashes and assessing for jaundice and pallor would not be related to this patient's potential cyanosis.

Which patient is ready for discharge from Phase 1 PACU care to the clinical unit? a. arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88% b. difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91% c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92% d. arouses, blood pressure higher than pre-op and respiratory rate is 10 no excess bleeding, SaO2 is 90%

ANS: c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92% Rationale: On initial assessment in PACU the airway, breathing, and circulation (ABC) status is assessed using a standardized tool that usually includes consciousness, respiration, oxygen saturation, circulation, and activity. Increased or decreased respiratory rate, hypertension, and a SaO2 below 90% indicate inadequate oxygenation that will be treated or managed in the PACU before discharging the patient to the next phase.

A common reason that a nurse may need extra time when preparing older adults for surgery is their a. ineffective coping b. limited adaptation to stress c. diminished vision and hearing d. need to include caregivers in activities

ANS: c. diminished vision and hearing Rationale: one of the major reasons that older adults need increased time pre-op is the presence of impaired vision/hearing that slows understanding of pre-op instructions and prep for surgery. Thought processes and cognitive abilities may also be impaired. the older adult's decreased adaptation to stress because of physiologic changes may increase surgical risks and overwhelming surgery related losses may result in ineffective coping that is not directly r/t time needed for pre-op preparation. the involvement of caregivers in pre-op activities may be appropriate for pts of all ages

How is the immune system altered in a burn injury? a. bone marrow stimulation b. increase in immunoglobulin levels c. impaired function of white blood blood cells d. overwhelmed by microorganisms entering denuded tissue

ANS: c. impaired function of white blood cells. Rationale: Burn injury causes widespread impairment of the immune system, with impaired WBC functioning, bone marrow depression, and a decrease in circulating immunoglobulins, which allows microorganisms to grow.

A patient with contact dermatitis is treated with calamine lotion. What is the rationale for using this base for a topical preparation. A. A suspension of oil and water to lubricate and prevent drying B. An emulsion of oil and water used for lubrication and protection C. Insoluble powders suspended in water that leave a residual powder on the skin D. A mixture of a powder and ointment that causes drying when moisture is absorbed.

ANS: c. insoluble powders suspended in water that leave a residual powder on the skin Rationale: A lotion is an emulsion of water, alcohol, and/or oil, Calamine has insoluble powser that has cooling and drying properties when the residual powder is left after water evaporation. It is useful when itching is present. Ointments and creams have an oil and water base that lubricate and ointments prevent drying. Creams protect skin and paste is a mixture of powder in an ointment base.

At the end of the emergent phase and the initial acute phase of burn injury, a patient has a serum sodium level of 152 mEq/L and a serum potassium level of 2.8 mEq/L. What could have caused these imbalances? a. free oral water intake b. prolonged hydrotherapy c. mobilization of fluid and electrolytes in the acute phase d. excessive fluid replacement with dextrose in water without potassium supplementation

ANS: c. mobilization of fluid and electrolytes in the acute phase. Rationale: At the end of the emergent phase, fluid mobilization moves potassium back into the cells and sodium returns to the vascular space, causing hypokalemia and hypernatremia. As diuresis in the acute phase continues, sodium will be lost in the urine and potassium will continue to be low unless it is replaced. Free oral water intake and prolonged hydrotherapy can cause a decrease in both sodium and potassium. Excessive fluid replacement with 5% dextrose in water without potassium supplementation can cause hyponatremia with hypokalemia.

During surgery, a patient has a nursing diagnosis of risk for peri-op positioning injury. What is a common risk factor for this nursing diagnosis? a. skin lesions b. break in sterile technique c. musculoskeletal deformities d. electrical or mechanical equipment failure

ANS: c. musculoskeletal deformities Rationale: Musculoskeletal deformities can be a risk factor for positioning injuries and require special padding and support on the operating table. Skin lesions and break in sterile technique are risk factors for infection and electrical or mechanical equipment failure may lead to other types of injury

To promote effective coughing, deep breathing, and ambulation in the post-op patient, what is most important for the nurse to do? a. teach the patient controlled breathing b. explain the rationale for these activities c. provide adequate and regular pain meds d. use an incentive spirometer to motivate the patient

ANS: c. provide adequate and regular pain meds Rationale: Incisional pain is often the greatest deterrent to patient participation in effective ventilation and ambulation and adequate and regular analgesic medications should be provided to encourage these activities. Controlled breathing may help the patient to manage pain but does not promote coughing and deep breathing. Explanations and use of an incentive spirometer help to gain patient participation but are more effective if pain is controlled.

Upon admission of a patient to the PACU, the nurse's priority nursing assessment is a. vital signs b. surgical site c. respiratory adequacy d. level of consciousness

ANS: c. respiratory adequacy Rationale: Physiologic status of the patient is always prioritized with regard to airway; breathing, and circulation, and respiratory adequacy is the first assessment priority of the patient on admission to the PACU from the operating room. Following assessment of respiratory function, cardiovascular, neurologic and renal function should be assessed as well as the surgical site.

In addition to ambulation, which nursing intervention could be implemented to prevent or treat the post-op complication of syncope? a. monitor vital signs after ambulation b. do not allow the patient to eat before ambulation c. slowly progress to ambulation with slow changes in position d. have the patient deep breathe and cough before getting out of bed

ANS: c. slowly progress to ambulation with slow changes in position Rationale: Slow progression to ambulation by slowly changing the patient's position will help to prevent syncope. Monitoring vital signs after walking will not prevent or treat syncope. Monitor the patient's pulse and blood pressure (BP) before, during, and after position changes. Elevate the patient's head, then slowly have the patient dangle, then stand by the bed to help determine if the patient is safe for walking. Eating will not have an effect on syncope. Deep breathing and coughing will not decrease syncope, although it will prevent respiratory complications.

A 24-year old female patient does not want the wound cleansing and dressing change to take place. she states, "what difference will it make anyway?" what will the nurse encourage the patient to do? a. have the wound cleaned and the dressing changed b. have a snack before having the treatments completed c. talk about what is troubling her with the nurse and/or family d. call the chaplain to com and talk to her and convince her to have the care

ANS: c. talk about what is troubling her with the nurse and/or family Rationale: There is a tremendous psychologic impact with a burn injury. Open communication with caregivers, close friends, and the burn team about fears regarding loss of life as she once knew it, loss of function, temporary or permanent deformity and disfigurement, return to routine life, financial burdens, rehabilitation, and her future are all essential. Simply convincing her to have the wound cared for ignores her psychologic, emotional, and perhaps spiritual needs.

Which burn patient should have nasotrachela or endotracheal intubation? a. carbon monoxide poisoning b. electrical burns causing cardiac dysrhythmias c. thermal burn injuries to the face, neck, or airway d. respiratory distress from eschar formation around the chest

ANS: c. thermal burn injuries to the face, neck, or airway Rationale: Patient's with major injuries involving burns to the face and neck require intubation within 1 to 2 hours after burn injury to prevent the need for emergency tracheostomy, which is done if symptoms of upper respiratory obstruction occur. Carbon monoxide poisoning is treated with 100% oxygen and eschar constriction of the chest is treated with an escharotomy.

How should the nurse position the patient with ear, face, and neck burns? a. prone b. on the side c. without pillows d. with extra padding around the head

ANS: c. without pillows Rationale: Patients with ear burns are not allowed to use pillows because of the danger of the burned ear sticking to the pillowcase, and patients with neck burns are not allowed to use pillows because contrctures of the neck can occur.

When performing a physical assessment of the skin, what should the nurse do first? a. Palpate the temperature of the skin with the fingertips. b. Assess the degree of turgor by pinching the skin on the forearm. c. Inspect specific lesions before performing a general examination of the skin. d. Ask the patient to undress completely so all areas of the skin can be inspected.

ANS: d. Ask the patient to undress completely so all areas of the skin can be inspected. Rationale: It is necessary for the patient to be completely undressed for an examination of the skin. Gowns should be provided and exposure minimized as the skin is inspected generally first, followed by a lesion-specific examination. Skin temperature is best assessed with the back of the hand and turgor is best assessed with the skin over the sternum.

During a pre-op review of systems, the patient reveals a history of renal disease. This finding suggests the need for which pre-op diagnostic tests? a. ECG and chest x-ray b. serum glucose and CBC c. ABGs and coagulation tests d. BUN, serum creatinine, and electrolytes

ANS: d. BUN, serum creatinine, and electrolytes Rationale BUN, serum creatinine, and electrolytes are used to assess renal function and should be evaluated before surgery. Other tests are often evaluated in the presence of diabetes, bleeding tendencies, and respiratory or heart disease

Which short-acting barbiturates are most commonly used for induction of general anesthesia? a. nitrous oxide b. propofol (diprivan) c. isoflurane (florane) d. Methohexital (Brevital)

ANS: d. Methohexital (brevital) Rationale: Nitrous oxide is a weak gaseous anesthetic. Propfol (Diprivan) is a nonbarbituate hypnotic that has a rapid onset any may be used for induction. Isoflurane (Forane) is a volatile liquid inhalation agent.

The patient is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure ulcer does the nurse expect to see on admission? a. Stage I b. Stage II c. Stage III d. Stage IV

ANS: d. Stage IV Rationale: Stage IV pressure ulcers are full-thickness tissue loss with muscle, tendon, or bone exposed. Stage 1 pressure ulcers are intact skin with nonblanchable localized redness. Stage II pressure ulcers have a shallow open area with a red-pink wound bed. Stage III pressure ulcers exhibit full-thickness tissue loss without bone, tendon, or muscle exposure with possible tunneling into the tissue.

Goals for patient safety in the OR include the Universal Protocol. What is included in this protocol? a. all surgical centers of any type must submit reports on patient safety infractions to the accreditation b. members of the surgical team stop whatever they are doing to check that all sterile items have been prepared properly c. members of the surgical team pause right before surgery to meditate for 1 minute to decrease stress and possible errors d. a surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site

ANS: d. a surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site Rationale: The universal protocol supported by the joint commission is used to prevent wrong site, wrong procedure, and wrong surgery in view of a high rate of these problems nationally. It involves pausing just before the procedure starts to verify patient identity, surgical site, and surgical procedure.

The health care provider has ordered IV morphine q2-4hr PRN for a patient following major abdominal surgery. When should the nurse plan to administer the morphine? a. before all planned painful activities b. every 2 to 4 hours during the first 48 hours c. every 4 hours as the patient requests the medication d. after assessing the nature and intensity of the patient's pain

ANS: d. after assessing the nature and intensity of the patient's pain Rationale: Before administering all analgesic medication, the nurse should first assess the nature and intensity of the patient's pain to determine if the pain is expected, prior doses of the medication have been effective, and any undesirable side effects are occurring. The administration of PRN analgesic medication is based on the nursing assessment. If possible, pain medication should be in effect during painful activities but activities may be scheduled around medication administration.

Which skin condition would be treated with laser surgery? A. Preauricular lesion B. Redundant soft tissue conditions C. Obesity with subcutaneous fat accumulation D. Fine wrinkle reduction or facial lesion removal

ANS: d. fine wrinkle reduction or facial lesion removal. Rationale: Laser surgery reduces fine wrinkles and removes facial lesions. A facelift is used for preauricular lesions and redundant soft tissue reduction. Liposuction is used for obesity with subcutaneous fat accumulation.

A patient with psoriasis is being treated with psoralen plus UVA light phototherapy. During the course of therapy, for what duration should the nurse teach the patient to wear protective eyewear that blocks all UV rays? A. Continuously for 6 hours after taking the medication B. Until the pupils are able to constrict on exposure to light C. For 12 hours following treatment to prevent retinal damage D. For 24 hours following treatment when outdoors or when indoors near a bright window

ANS: d. for 24 hours following treatment when outdoors or when indoors near a bright window. Rationale: Prosalen is absorbed by the lens of the eye and eyewear that blocks 100% of UV light must be used for 24 hours after taking the medication. Because UVA penetrates glass, the eyewear must also be worn indoors when near a bright window. Psoralen does not affect the accommodative ability of the eye.

Chapter 17 Which procedures are done for curative purposes (select all that apply)? a. gastroscopy b. rhinoplasty c. tracheotomy d. hysterectomy e. herniorrhaphy

ANS: d. hysterectomy e. herniorrhaphy Rationale: Gastroscopy is done for the purpose of diagnosis; rhinoplasty is done for a cosmetic improvement; a tracheotomy is palliative.

Which characteristics are true about chemical burns? (select all that apply) a. metabolic asphyxiation may occur b. metabolic acidosis occurs immediately following the burn c. the visible skin injury often does not represent the full extent of tissue damage d. lavaging with large amounts of water is important to stop the burning process with these injuries e. alkaline substances that cause these burns continue to cause tissue damage even after being neutralized

ANS: d. lavaging with large amounts of water is important to stop the burning process with these injuries e. alkaline substances that cause these burns continue to cause tissue damage even after being neutralized Rationale: With chemical burns, removing the chemical from the skin is important. Lavaging the skin with water or saline solution for 20 minutes to 2 hours postexposure may be needed. Alkali tends to adhere to skin and causes prolonged damage with protein hydrolysis and liquefaction. Metabolic asphyxiation is from the inhalation of carbon monoxide or hydrogen cyanide. Metabolic acidosis is most common in electrical burns, as is the "iceberg effect" of tissue injury below the skin.

What characteristic is commonly seen with dysplastic nevus syndrome? A. Associated with sun exposure B. Precursor of squamous cell carcinoma C. Slow-growing tumor with rare metastasis D. Lesion has irregular color and asymmetric shape

ANS: d. lesion has irregular color and asymmetric shape Rationale: Dysplastic nevus syndrome involves atypical moles with irregular borders and various shades of color. Dysplastic nevus syndrome may be a precursor of malignant melanoma, although not directly related to sun exposure. There are frequently multiple nevi to monitor.

The patient will be placed under moderate sedation to allow realignment of a fracture in the emergency department. When the family asks about this anesthesia, what should the nurse tell them? a. includes inhalation agents b. induces high level of sedation c. frequently used for traumatic injuries d. patients remain responsive and breathe without assistance

ANS: d. patients remain responsive and breathe without assistance Rationale: Moderate sedation uses sedative, anxiolytic, and/or analgesic medications. Inhalation agents are not used. It is not expected to induce levels of sedation that would impair a patient's ability to protect the airway.

A patient has a 20% TBSA deep partial-thickness and full-thickness burn to the right anterior chest and entire right arm. what is important for a nurse to assess in this patient? a. presence of pain b. swelling of the arm c. formation of eschar d. presence of pulses in the arms

ANS: d. presence of pulses in the arms. Rationale: In circumferential burns, circulation to the extremities can be severely impaired, and pulses should be monitored closely for signs of obstruction by edema. Swelling of the arms would be expected, but it becomes dangerous when it occludes blood vessels. Pain and eschar are also expected.

Monitored anesthesia care (MAC) is being considered for a patient undergoing a cervical dilation and endometrial biopsy in the health care clinic. The patient asks the nurse, "What is this MAC?" The nurse's response is based on the knowledge that MAC a. can be administered only by anesthesiologists or nurse anesthetists b. should never be used outside of the OR because of the risk of serious complications c. is so safe that it can be administered by nurses with direction from health care providers d. provides maximum flexibility to match the sedation level with the patient and procedure needs

ANS: d. provides maximum flexibility to match the sedation level with the patient and procedure needs Rationale: MAC refers to sedation that is similar to general anesthesia using sedative, anxiolytic, and/or analgesic medication. It can be administered by an ACP. The patient must be assessed and the physiologic problems that may develop must be managed because of the high risk of complications.

Chapter 11: In a patient with leukocytosis with a shift to the left, what does the nurse recognize as causing the finding? a. the complement system has been activated to enhance phagocytosis b. monocytes are released into the blood in larger-than-normal amounts. c. the response to cellular injury is not adequate to remove damaged tissue and promote healing. d. the demand for neutrophils causes the release of immature neutrophils from the bone marrow.

ANS: d. the demand for neutrophils causes the release of immature neutrophils from the bone marrow. Rationale: A shift to the left is the term used to describe the presence of immature, banded neutrophils in the blood in response to an increased demand for neutrophils during tissue injury. Monocytes are increased in leukocytosis but are mature cells.

At the end of the surgical procedure, the peri-op nurse evaluates the patient's response to the nursing care delivered during the peri-op period. What reflects a positive outcome related to the patient's physical status? a. the patient's right to privacy is maintained throughout the procedure b. the patient's care is consistent with the pre-planned peri-op plan of care c. the patient receives consistent and comparable care regardless of the surgical setting d. the patient's respiratory function is consistent with or improved from baseline levels established pre-op.

ANS: d. the patient's respiratory function is consistent with or improved from baseline levels established pre-op. Rationale: The peri-op nursing data set includes outcome statements that reflect standards and recommended practices of peri-op nursing. Outcomes r/t physiologic responses include those of physiologic function; peri-op safety includes the patient's freedom from any type of injury; and behavioral responses include knowledge and actions of the patient and family, including the consistency of the patient's care with the peri-op plan and the patient's right to privacy

The nurse is reviewing the lab results for a pre-op patient. Which test result should be brought to the attention of the surgeon immediately? a. serum K+ of 3.8 mEq/L b. hemoglobin of 15 g/dL c. blood glucose of 100 mg/dL d. white blood cell count of 18,500/uL

ANS: d. white blood cell count of 18,500/uL Rationale: finding may indicate an infection. the surgeon will probably postpone the surgery until the cause of the elevated WBC count had been found

Which drainage is drained with a Hemovac? a. bile b. urine c. gastric contents d. wound drainage

ANS: d. wound drainage Rationale: Bile is drained by a T-tube, urine is drained by an indwelling urinary catheter, and gastric contents are drained by a nasogastric tube or a gastrointestinal tube.

Thirty-six hours post-op a patient has a temperature of 100 degrees Fahrenheit. What is the most likely cause of this temperature elevation? a. dehydration b. wound infection c. lung congestion and atelectasis d. normal surgical stress response

Ans: d. normal surgical stress response Rationale: During the first 24-48 post-op hours, temperature elevation to 100.4 are a result of the inflammatory response to surgical stress. Dehydration and lung congestion or atelectasis in the first 2 days will cause a temp elevation above 100.4 F. Wound infections usually do not become evident until 3 to 5 days post-op and manifest with temperatures above 100 F.

Blebs can be removed from facial skin grafts by __________.

aspirating the fluid with a tuberculosis syringe, performed by individuals trained in this skill

A permanent skin graft that may be available for the patient with large body surface area burns who has limited skin for donor harvesting is __________.

cultured epithelial autograft