Med- Surge Integ

A health care provider prescribes oral loperamide (Maalox) and intravenous ranitidine (Zantac) for a client with burns and crushing injuries caused by an accident. The client asks how these medications work. The nurse's best response is:

"They limit acidity in the gastrointestinal tract."

A client is admitted to the hospital with severe burns. What client response should the nurse anticipate when caring for the client during the acute phase of burn recovery?

Stable vital signs

A client is admitted for malignant melanoma that was discovered during a routine eye examination. For which preferred treatment does the nurse expect the client to be scheduled?

Enucleation

A nurse epidemiologist is responsible for wound consults at the hospital where a client has been admitted with an infected wound. The client asks, "What is the primary role of a nurse epidemiologist?" The nurse explains that the nurse epidemiologist:

Helps health care providers to control infections

A nurse is preparing to give a client a tepid bath and uses a bath thermometer to test the water temperature. What is the acceptable temperature range for a tepid bath? 1 92° to 94° F 2 95° to 97° F 3 98° to 100° F 4 101° to 103° F

98° to 100° F

A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force?

30 degrees

A health care provider tells a client that vitamin E and beta-carotene are important for healthier skin. Which foods should the nurse recommend that are excellent sources of both of these substances? 1 Spinach and mangoes 2 Fish and peanut butter 3 Oranges and grapefruits 4 Carrots and sweet potatoes

Spinach and mangoes

When caring for a client, what clinical indicators should the nurse immediately report to the health care provider? (Select all that apply.) 1 Weakness 2 Diaphoresis 3 Tachycardia 4 Cold extremities 5 Flushed skin tone

Weakness Diaphoresis Tachycardia Cold extremities

The nurse stops at an accident scene to administer emergency care for a person who has sustained partial- and full-thickness burns to the chest, right arm, and upper legs as the result of a car fire. What should the nurse do first when caring for this person?

Wrap the person in a clean, dry sheet

An older client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" What is the best response by the nurse? 1 "You sound upset, but your health care provider knows best. You should do what is prescribed." 2 "Your spouse is very capable, but if your burns get infected, a family member can't give you the injections you will need." 3 "Your burns are more serious than you think, and we have specially trained people here just to take care of you." 4 "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

"You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. Performing an immediate appraisal, using the Rule of Nines, what is the percent of body surface area burned? 1 18% 2 22.5% 3 27% 4 36.5%

22.5%

A health care provider prescribes 2 L of intravenous (IV) fluid to be administered every 12 hours to a client who sustained a burn injury. The drop factor of the tubing is 10 gtts/mL. The nurse should set the flow rate at how many drops per minute? Record your answer using a whole number. __________ gtts/min Multiply the amount to be infused (2000 mL) by the drop factor (10), and divide the result by the amount of time in minutes (12 hours × 60 min).

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A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? (Select all that apply.) 1 Age 2 Anorexia 3 Hemiplegia 4 History of diabetes 5 Urinary incontinence

Anorexia Hemiplegia Urinary incontinence

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement?

Beginning realization of implications for the future

The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered to a person that suffers extensive burns. An appropriate response by the nurse is to call 911 and: 1 Apply ice to burned areas; the intervention will decrease pain 2 Use first aid cream to burned areas 3 Do nothing; attempting to treat the burned areas may cause further damage 4 Cover the burned areas with a bed sheet

Cover the burned areas with a bed sheet

A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. For what physiological response to the radiation should the nurse assess the client during the return visit to the radiology department?

Dysphagia

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? (Select all that apply.) 1 Eat foods high in vitamin C. 2 Take your temperature daily. 3 Balance periods of rest and activity. 4 Use a strong soap when washing the skin. 5 Expose the skin to the sun as often as possible

Eat foods high in vitamin C. Take your temperature daily. Balance periods of rest and activity.

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound?

In the preoperative period

What are expected changes that the nurse might identify when assessing the skin of an older adult? (Select all that apply.) 1 Scaly skin 2 Increased wrinkles 3 Signs of ecchymosis 4 Marked flaking of skin 5 Hyperpigmented patches

Increased wrinkles Hyperpigmented patches

A client with burns over 35% of the body complains of chilling. To promote client comfort, the nurse should:

Limit Room drafts

A nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the primary concern of the nurse when caring for this client?

Skin integrity

A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly?

Strawberries

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. What is an appropriate nursing response? 1 The epidermis is damaged 2 The dermis is damaged partially 3 Both the epidermis and the dermis are destroyed 4 The structures beneath the skin are destroyed

The epidermis is damaged

A carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm again and I'll be scarred forever" The nurse's best initial response is: 1 "The staff is taking steps to minimize scarring." 2"Think about how lucky you are. You are alive." 3 "Try not to worry for now. Concentrate on your range-of-motion exercises." 4"I know you're worried, but it is too early to tell how much scarring will occur."

"I know you're worried, but it is too early to tell how much scarring will occur."

The nurse is providing care for a client that is on bed rest. The nurse can prevent skin breakdown for this client by: 1 Massaging the bony prominences 2 Maintaining a sheepskin pad under the client 3 Promoting range-of-motion activities 4 Encouraging the client to move around as much as possible

Encouraging the client to move around as much as possible

A client is admitted for malignant melanoma that was discovered during a routine eye examination. For which preferred treatment does the nurse expect the client to be scheduled? 1 Radiation 2 Enucleation 3 Cryosurgery 4 Chemotherapy

Enucleation

A client was admitted with full-thickness burns two weeks ago. Since admission, the client has lost an average of a pound of weight each day. The nurse expects the client's diet to be adjusted to include: 1Low-sodium milk 2High protein drinks 3Foods that are low in potassium 4 Ten percent more calories in the form of fats

High protein drinks

During the first 48 hours after a thermal injury, the nurse should assess the client for:

Hyperkalemia and hyponatremia

After a basal cell carcinoma is removed by fulguration, a client is given a topical steroid to apply to the surgical site. The nurse evaluates that the teaching regarding steroids and skin lesions is effective when the client states that the primary purpose of the medication is to:

Reduce inflammation at the surgical site

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase? 1 Alleviate pain 2 Prevent infection 3 Replace blood loss 4 Restore fluid volume

Restore fluid volume

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? (Select all that apply.) 1 Scaly lesions 2 Pruritic lesions 3 Reddened papules 4 Multiple petechiae 5 Erythematous maculesg

Scaly lesions Pruritic lesions Reddened papules

When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating:

Shellfish

In response to a client's question, the nurse explains the difference between partial-thickness (second-degree) burns and full-thickness (third-degree) burns. What information about partial-thickness burns should the nurse include in the discussion? 1 They are painful, reddened, and have blisters 2 Grafting will be required before they can heal 3 There is destruction of both the epidermis and dermis 4 Months of extensive treatment are required before healing

They are painful, reddened, and have blisters

When assessing a wound that is healing by secondary intention, the nurse can classify it according to its condition and color. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?

Yellow

A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at an angle of:

30 degrees

A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aide station. The nurse encourages the client to seek medical attention but the client refuses. The nurse advises the person to go to a health care provider if: 1 Blisters appear 2 Urinary output decreases 3 Edema and redness occur 4 Low-grade fever develops

Urinary output decreases