HURST! BURNS

The nurse is assessing a 70 year old client who was admitted several hours ago for IV hydration with lactated ringers solution after being diagnosed with dehydration. What findings would be of concern to the nurse? Select all that apply

-BP 142/88 -BOUNDING PULSE -CVP 7MMHG -S3 HEART SOUND

A client is to be discharged following treatment for hepatitis A. The nurse knows teaching was successful when the client makes what statement?

I CAN DONATE BLOOD WHEN I AM WELL

A renal transplant client has received discharge education. Which statement by the client indicates that further teaching is necessary?

I WILL BE ON STEROIDS FOR 3 MONTHS THEN I WILL NOT HAVE TO TAKE THEM

A client arrives at the emergency department after sustaining full thickness burns. What does the nurse estimate the total body surface area (TBSA) burned to be when using the rule of nines?

POSTERIOR BACK AND POST ARM 18+4.5=22.5

The nurse is performing a routine history and physical on a client who attends the Senior Citizen's Center. What finding noted by the nurse would suggests that the client may have a history of chronic emphysema?

-BARREL CHEST -REPORTS FREQUENT MORNING HEADACHES

What signs/symptoms would the nurse expect to assess in a client diagnosed with exocrine pancreatic cancer?

-DARK TEA COLORED URINE -CLAY COLORED STOOLS -JAUNDICE

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate?

1. Assess entry and exit wound. 2. Monitor vital signs. 3. Place on a spine board. 4. Connect to cardiac monitor. 6. Apply cervical collar to neck.

The nurse is caring for a ventilator-dependent client assisted with positive expiratory end pressure (PEEP). The high-pressure alarm begins sounding. What actions should the nurse initiate? Select all that apply

1. Check to see if client is biting ET tube. 2. Examine tubing for presence of water. 5. Assess client's need for suctioning.

What sign/symptom would indicate to the nurse that a client has had an inhalation injury?

1. stridor 2. Swallowing difficulty 3. Singed nasal hair 5. Wheezing

What teaching points should the nurse include when educating a client how to prevent a venous stasis ulcer? Select all that apply

2. Perform leg exercises regularly. 3. Wear graduated compression stockings. 4. Treat itching with prescribed topical corticosteroids. 5. Minimize stationary standing.

What information on burn prevention strategies should the nurse include when providing an education program at a community center?

2. Clean the lint trap on the clothes dryer after each use. 4. Do not hold a child while holding a hot drink. 5. Home hot water heater should be set at a maximum of 120°F (48.8°C).

A client weighing 166 pounds (75 kg) is brought to the emergency room with burns to the front and back of both legs and feet. Using the American Burn Association formula to calculate the amount of fluid needed for the first 24 hours, the nurse should set the infusion rate at what for the first eight hours? (Round to nearest whole number).

338 The American Burn Association formula is 2 - 4mL x weight in kilograms x total surface area burned. Based on the Rule of Nines for adults, a leg is 9% on the front and 9% on the back, which includes the feet. So both legs equal 36% (9% times 4) total surface area burned. The standard multiplier for thermal burns is considered to be 2 mL. Therefore: 2mL x 75 kg x 36 = 5,400 mL for 24 hours. Half that amount, or 2700 mL, should be infused in the first eight hours. Dividing that amount by 8 hours, the infusion rate would be 338 mL per hour.

What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim?

Briefly soak burned area in cool water. Correct: Although all options are correct, the priority is to stop the burning process. Just putting out the flames is not enough to stop the burning process. You need to apply cool water briefly (no more than 10 minutes) to soak the burn area. Any longer can cause extensive heat loss.

An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect?

Carbon monoxide poisoning

What preoperative information should the nurse provide to the client who is scheduled for an exercise stress test tomorrow morning?

DRESS IN LOOSE COMFORTABLE CLOTHING

The nurse is teaching a group of high school students about car accident prevention. Who would the nurse include as the highest risk for a motor vehicle crash (MVC)?

DRIVERS WHO HAVE RECENTLY ACQUIRED A LICENSE

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action?

Gently remove the debris and re-dress the wound.

A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests?

HCT POTASSIUM CREATININE

A client presents to the emergency department (ED) with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism. Which electrolyte imbalance would be the nurse's priority concern?

HYPOMAGNESEMIA

An elderly client with partial and full-thickness burns has begun receiving fluids at 600 ml/hour, as determined by the Parkland (Consensus) Formula. Based on the assessment data for the first four hours, what should the nurse report to the primary healthcare provider?

The changes in vital signs indicate an expected response to fluids 3. CORRECT. The purpose of infusing large amounts of fluid into burn victims during the first 24 hours is to help maintain perfusion until the body's physiology returns to normal functioning. The serial vital signs indicate the cardiovascular system is stabilizing, as evidenced by pulse decreasing to the normal range while blood pressure increases. Though respirations are still slightly elevated, the client would likely be experiencing pain. Most importantly, the CVP (central venous pressure) has increased to the normal range, indicating the fluid replacement is adequate at this time.