Evolve Integ
A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first aid measure that a nurse should instruct the person to apply before seeking health care?
Cool, moist towels
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?
98° to 100° F
The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue?
Blistered and wet
A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets
2
A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is:
36
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?
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:
A client is scheduled for surgery. Legally, the client may not sign the operative consent if:
Any sedative type of medication has been given recently
During a first aid class, a student asks what should be done if a person's clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to:
Assess the person's breathing
A client newly diagnosed with scleroderma states, "Where did I get this from?" The nurse's best response is "Although no cause has been determined for scleroderma, it is thought to be the result of:
Autoimmunity.
A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. The nurse's teaching plan should include instructions to:
Clean the mouth with a soft toothbrush or a gentle spray
A client is receiving patient-controlled analgesia (PCA) after surgery. The nurse determines that with this type of therapy the:
Client is able to self-administer pain-relieving drugs as necessary
A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes?
Deep breathing exercises
A client receives a scalding burn to the chest and arms. The nurse assesses that the burned areas are painful, mottled red, weeping, and edematous. These burns are classified as:
Deep partial-thickness burns
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
An client who is obese must self-administer insulin using an insulin syringe. The technique that the nurse teaches the client to use is to:
Inject at a 90-degree angle
In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. The nurse identifies that the client understands the instructions when the client states, "I will:
Inspect the incision for healing when I change the dressing."
The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches that the most effective method for putting out the flames is to:
Log-roll the victim in the grass
A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends
Meatloaf and strawberries
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?
Spinach and mangoes
Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is nothing by mouth (NPO) is complaining of severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do?
Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is nothing by mouth (NPO) is complaining of severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do?
A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. During the first two to three days after the burn to monitor fluid balance, it is important for the nurse to assess the:
Urinary output every hour
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:
"I know you're worried, but it is too early to tell how much scarring will occur."
A client with burns tells the nurse that the primary health care provider stated that skin grafts would be required. The client asks when the procedure will be performed. The most appropriate nursing response is:
"Tell me what your primary health care provider said about the graft procedure."
A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. Considering this finding, the nurse should assess the client for:
Prolonged wound healing
The nurse is caring for two clients. The first client had a below-the-knee amputation as a result of an accident. The second client had a below-the-knee amputation because of chronic decreased arterial perfusion. The nurse anticipates that the postoperative courses of these two clients may differ because the:
Second client's incision will take longer to heal
A client newly diagnosed with scleroderma states, "Where did I get this from?" The nurse's best response is "Although no cause has been determined for scleroderma, it is thought to be the result of
Autoimmunity."
A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. What is the best response by the nurse?
"May I take a look at it?"
Following surgery, a client received a prescription for 8 mg of morphine sulfate to be given by injection. The vial on hand is labeled 1 mL = 10 mg. How much solution should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal point. __________ mL
0.8
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 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 client with burns is to receive the exposure method of treatment with application of mafenide (Sulfamylon) twice a day. With this type of treatment the nurse plans to:
Administer prescribed pain medication
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
When a nurse is evaluating the condition of a client with burns of the upper body, a sign that indicates potential respiratory obstruction is:
Hoarse quality to the voice
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
A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. The nurse is
Negligent and can be sued for malpractice
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 client with pulmonary tuberculosis discusses the dietary plan with the nurse. The nurse expects that the type of diet that will be prescribed for the client is:
Small, frequent, high-calorie meals
A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching?
Using a back-and-forth motion while cleaning the wound
Before administering preoperative medication to a client, the nurse plans to:
Verify the consent
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 male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. The best initial response by the nurse is:
"Can you tell me why you decided to refuse the procedure?"
A client develops a maculopapular rash on the upper extremities and audible wheezing during the administration of intravenous vancomycin (Vancocin). To ensure the client's safety, which action would the nurse carry out first?
Stop infusion
When changing a postoperative client's dressing, the nurse is careful not to introduce microorganisms into the incision. What type of asepsis includes this principle?
Surgical asepsis
A client with burns tells the nurse that the primary health care provider stated that skin grafts would be required. The client asks when the procedure will be performed. The most appropriate nursing response is:
Tell me what your primary health care provider said about the graft procedure."
A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client?
Highly contagious
During the first 48 hours after a thermal injury, the nurse should assess the client for
Hyperkalemia and hyponatremia
A nurse is caring for a client with severe burns. The nurse determines that this type of client is at risk for hypovolemic shock because of the:
Plasma proteins moving out of the intravascular compartment
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 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?
The epidermis is damaged
A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the Rule of Nines. Record your answer using one decimal place. ________%
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
28
The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. The nurse concludes that the most probable reason for the noncompliance is that during the exercises:
Pain at the incision site increases