MedSurg II - Exam 3 - Ch. 57 Burns, Ch. 28, 29, 30

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. Infection Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells Inadequate formed white blood cells

Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells Explanation: Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms.

A client is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? Assess for edema. Assess skin integrity frequently. Assess the client's level of consciousness frequently. Closely monitor intake and output.

Closely monitor intake and output. Explanation: The client with DIC is at a high risk of deficient fluid volume. The nurse can best gauge the effectiveness of care by closely monitoring the client's intake and output. Each of the other assessments is a necessary element of care, but none addresses fluid balance as directly as close monitoring of intake and output.

The nurse recognize what as an early sign of sepsis in a client with a burn injury? Normal body temperature Decreased heart rate Elevated serum glucose Widened pulse pressure

Elevated serum glucose In clients with burn injuries early sepsis can be hard to detect. Clients with burn injuries exhibit tachycardia, tachypnea, and elevated body temperature, all typical indications of sepsis. In the client with burn injury, indications of sepsis include elevated serum glucose values, increased heart rate, and narrowing mean arterial pressure. Both the typical elevated temperature and a temperature of less than 96.8 F (36 C) can indicate sepsis in a client with a burn injury.

A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client? Endotracheal tube insertion Tracheostomy Escharotomy Ventilator assisted breathing

Escharotomy In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharotomy is performed to release the burn tissue on the anterior chest, freeing the chest for expansion with inspiration. Endotracheal tube insertion, tracheostomy, and ventilation do not correct the tightening of the chest and poor expansion issue.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? Full-thickness Superficial Superficial partial-thickness Deep partial-thickness

Full-thickness A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

A nurse is caring for a client with iron deficiency anemia. Which food or beverage will the nurse suggest to the client to eat or drink when taking supplemental iron? Milk Orange juice Leafy green vegetables Kidney beans

OJ Vitamin C found in orange juice improves the absorption of iron. The other answer choices are not the best for improving absorption of iron.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to fat emboli Related to infection Related to femoral artery occlusion Related to circumferential eschar

Related to circumferential eschar As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

A nurse is caring for a client with thalassemia who is being transfused. What is the nurse's role during a transfusion? To closely monitor the rate of administration To administer vitamin B12 injections To instruct the client to rest immediately if chest pain develops To assess for enlargement and tenderness over the liver and spleen

To closely monitor the rate of administration Explanation: In a client with thalassemia, when transfusions are necessary, the nurse closely monitors the rate of administration. Assessing for enlargement and tenderness over the liver and spleen, advising rest, or administering vitamin B12 injections are not indicated for thalassemia.

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "Are the victims suffering from thermal burns?" "How many victims are anticipated for transport?" "Are the burns associated with chemicals used in the plant?" "Are any of the victims expected to have electrical burns?"

"Are the burns associated with chemicals used in the plant?" If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel.

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia? "I feel hot all of the time." "I have a difficult time falling asleep at night." "I have difficulty breathing when walking 30 feet." "I have an increase in my appetite."

"I have difficulty breathing when walking 30 feet." Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigued and able to sleep often with a decrease in appetite, not an increase.

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 18% 27% 30% 36%

36%

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 10 mL/hr A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr

A urinary output of 30 mL/hr For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).

A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse? Assesses the hemoglobin level Questions the administration of both medications Ensures the client has completed dialysis treatment Holds the epoetin alfa if the BUN is elevated

Assesses the hemoglobin level Explanation: Erythropoietin (epoetin alfa [Epogen]) with oral iron supplements can raise hematocrit levels in the client with end-stage renal disease. The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for heart failure, myocardial infarction, and cerebrovascular accident. Erythropoietin may be administered during dialysis treatments. The BUN will be elevated in the client with end-stage renal disease.

You are caring for a 13-year-old diagnosed with sickle cell anemia. The client asks you what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client? Avoid any sports that tire you out. Drink at least 8 glasses of water every day. Avoid any activity that makes you short of breath. Stay on oxygen therapy 24/7.

Drink at least 8 glasses of water every day. Explanation: During the physical examination, observe the client's appearance, looking for evidence of dehydration, which may have triggered a sickle cell crisis. Clients are taught moderation, not avoidance of activities. Most clients with sickle cell disease are not on oxygen therapy 24/7.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hyperkalemia. Hypernatremia. Hypocalcemia. Hypoglycemia.

Hyperkalemia. Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat? Shrimp and tomatoes Lobster and squash Cheese and bananas Lamb and peaches

Lamb and peaches

A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention? Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential Monitoring the client's breathing and reviewing the client's arterial blood gases Monitoring the client's heart rate and reviewing the client's hemoglobin Monitoring the client's blood pressure and reviewing the client's hematocrit

Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential Explanation: Clients with neutropenia often do not exhibit classic signs of infection. Fever is the most common indicator of infection, yet it is not always present. No definite symptoms of neutropenia appear until the client develops an infection. A routine CBC with differential can reveal neutropenia before the onset of infection.

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? Music therapy may provide reality orientation, distraction, and sensory stimulation. Music therapy diverts the client's attention toward painful stimulus. Humor therapy has not proven effective in the management of burn pain. Pet therapy has proven effective in the management of burn pain.

Music therapy may provide reality orientation, distraction, and sensory stimulation.

As the first priority of care, a patient with a burn injury will initially need: a patent airway established. an indwelling catheter inserted. fluids replaced. pain medication administered.

a patent airway established. Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen.

A client has pernicious anemia and has been receiving treatment for several years. Which symptom may be confused with another condition in older adults? dementia stomatitis glossitis ataxia

dementia Pernicious anemia may be accompanied by a dementia with symptoms similar to Alzheimer's disease. Therefore, clients experiencing cognitive changes should be screened because early detection of pernicious anemia is critical to prevent neurologic damage.