NURS 2900/2920- Burns/ peri-op care

4) The postoperative recovery room nurse determines that a client in the postoperative phase of care can be transitioned to Phase II of recovery. The client is able to take deep breaths and cough, is using oxygen to maintain a saturation of greater than 90%, is fully awake, has a systolic blood pressure that is 130 mmHg now but the preoperative systolic blood pressure was 100 mmHg, and is able to move all four extremities independently. Using the following scale, this client's Aldrete score is ________. The Aldrete score Respiration 2 = Able to take deep breath and cough 1 = Dyspnea/shallow breathing 0 = Apnea O2 Saturation 2 = Maintains > 92% on room air 1 = Needs O2 inhalation to maintain O2 saturation > 90% 0 = Saturation < 90% even with supplemental oxygen Consciousness 2 = Fully awake 1 = Arousable on calling 0 = Not responding Circulation 2 = BP+ 20 mmHg preop 1 = BP+ 20-50 mmHg preop 0 = BP+ 50 mmHg preop Activity 2 = Able to move 4 extremities 1 = Able to move 2 extremities 0 = Able to move 0 extremities

8

3) The postoperative nurse is planning care for a client recovering from major thoracic surgery. Which diagnoses should the nurse select to plan for this client's immediate care needs? Select all that apply. A) Risk for Impaired Gas Exchange B) Risk for Decreased Cardiac Output C) Risk for Ineffective Airway Clearance D) Risk for Imbalanced Nutrition: Less than Body Requirements E) Risk for Imbalanced Fluid Volume

A, B, E Explanation: A) Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. The Risk for Ineffective Airway Clearance might be appropriate later as the client recovers from surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.

room suite. Which individuals should the nurse emphasize when discussing this aspect of the surgical process with the client? Select all that apply. A) Surgeon B) Postoperative nurse C) Circulating nurse D) Anesthesiologist E) Social worker

A, C, D Explanation: A) The surgeon performs the procedure. The postoperative nurse will provide care to the client after the surgery is completed. The circulating nurse is a perioperative registered nurse who cares for the client during the surgical procedure. The anesthesiologist provides the anesthesia during the surgery and continually monitors the client's physiologic status. The social worker will not be in attendance during the procedure but may become involved in the client's care during the preoperative and postoperative phases

8) The nurse is preparing an older client for surgery. On what should the nurse focus when preparing this client's preoperative teaching? Select all that apply. A) Level of hearing B) Including the family in the perioperative care plan C) Teaching on deep breathing and coughing D) Plans for discharge care E) Actions to prevent pressure ulcers

A, C, D, E Including the family as much as possible in perioperative care plan would be appropriate for a pediatric client. For the older client, make sure the client can hear the information to be presented or provide information through alternative means. Older adults are at greater risk for pneumonia and other postoperative complications and should have teaching related to deep breathing and coughing. The older client is going to need assistance once discharged and should have the necessary medical equipment such as walkers and raised toilet seats, assistance with transportation, or extended care. The older client is at risk for pressure ulcer formation because of poor nutritional status, diabetes, cardiovascular illness, or history of steroid use

7) The nurse is planning care for a client in the acute stage of a burn injury. Which areas will be included in the plan of care? Select all that apply. A) Nutrition B) Psychosocial support C) Pain management D) Fluid resuscitation E) Wound care

A, C, E Explanation: A) Nursing care for the client during the acute stage of burn injuries will include wound care, nutritional therapy, and pain management. Fluid resuscitation occurs during the emergency phase of burn care. Psychosocial support will be needed once the client has stabilized.

Exemplar 21.1 Burns 1) A nurse working in the pediatric intensive care unit (PICU) is planning care for a pediatric client who is being admitted with a partial-thickness thermal burn. What is true regarding this type of burn? A) Partial-thickness burns are deeper than superficial burns but still involve the epidermis only. B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. C) A deep partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. D) A superficial partial-thickness burn is less painful than a deep partial-thickness burn

B Explanation: A) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site

9) A client recovering from surgery begins to have an increase in body temperature and carbon dioxide level. What should the nurse do first? A) Assess for patent intravenous line. B) Provide 100% oxygen with a nonrebreather mask. C) Provide dantrolene. D) Contact the anesthesiologist

B Explanation: A) An increase in body temperature and carbon dioxide level are indications that the client is developing malignant hyperthermia. The first thing the nurse should do is apply 100% oxygen with a nonrebreather mask. The nurse should then ensure good intravenous access and contact the anesthesiologist. The anesthesiologist will prescribe dantrolene for administration

6) A client who sustained burns to both lower extremities complains to the nurse about feeling frustrated by not being able to provide self-care. Which nursing diagnosis would be appropriate for the client at this time? A) Ineffective Coping B) Powerlessness C) Anxiety D) Situational Low Self-Esteem

B Explanation: A) The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low-self-esteem, ineffective coping, or anxiety

5) An older client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client's intake and output, what should be taken into consideration? A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase. C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins. D) The amount of urine output will be greatest in the first 24 hours after the burn injury.

B Explanation: A) The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury

5) A client is admitted with the diagnosis of fever of unknown origin. Which diagnostic test(s) will the nurse expect the client to have performed? Select all that apply. A) CT scan of the abdomen B) Chest x-ray C) Urinalysis D) Complete blood count E) Bone scan

B, C, D Explanation: A) The diagnostic tests will focus on trying to find the cause of the elevated body temperature. The complete blood count will be done to see if there is an elevation in white blood cells. The urinalysis will be done to see if the client has a urinary tract infection. The chest x-ray will be done to see if the client has a lung infection. A bone scan and CT scan of the abdomen may or may not be indicated for this client

Module 17 Perioperative Care The Concept of Perioperative Care 1) A client is informed that a surgical procedure is to be scheduled in 2 weeks. On what teaching should the nurse focus to prepare the client for the surgery? Select all that apply. A) Maintaining a patent airway B) Deep breathing and coughing C) Caring for the surgical incision D) Managing constipation E) Managing pain

B, C, D, E

6) The nurse is preparing a client for emergency surgery to repair liver and colon lacerations caused by a motor vehicle crash. What information about this type of surgery will the nurse use to guide the client's care? Select all that apply. A) An organ is going to be removed. B) This is an emergency surgery. C) The client will be hospitalized longer. D) The client is at risk for blood loss. E) The client is at risk for hypothermia.

B, C, D, E Explanation: A) The suffix -ectomy indicates removal of an organ. The client is having surgery to repair lacerations. No organ is identified for removal. Emergency surgery is performed when a condition is life-threatening. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. Open procedures place the client at a higher risk for blood loss. If there is a large surgical opening, the client cannot be adequately covered and will be exposed to cold surgical suite air, and can develop hypothermia

5) The postoperative care nurse reviews the documentation from the intraoperative phase and determines that several areas are missing. Which areas did the nurse identify as being missing from the intraoperative documentation? Select all that apply. A) Pain assessment B) Start and stop times of anesthesia C) Medication review D) Antibiotic infusion times E) Start and stop times of the procedure

B, D, E

A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified? A) Minor B) Moderate C) Major D) Significant

C Explanation: A) According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.

Module 20 Thermoregulation The Concept of Thermoregulation 1) Victims of a boating accident were admitted to the hospital with the diagnosis of hypothermia. What should the nurse realize as the method by which these clients lost body temperature? A) Vaporization B) Insensible water loss C) Convection D) Insensible heat loss

C Explanation: A) Convection is the process of heat transfer through the fluid motion of air or water across the skin. The clients of a boating accident developed hypothermia through convection. Vaporization is the continuous evaporation of moisture through the respiratory tract, mucosa of the mouth, and skin. Insensible water loss is unnoticed water loss through vaporization. Insensible heat loss is the loss of heat through vaporization.

10) A nurse working in labor and delivery understands that newborns are at great risk for alterations of thermoregulation. By drying the newborn immediately after birth, the nurse is protecting heat loss by which method? A) Convection B) Conduction C) Evaporation D) Radiation

C Explanation: A) Evaporation is the process of converting water to a vapor. This is the method of heat loss that occurs when a newborn baby is not dried properly. Convection is the process of heat transfer through the fluid motion of air or water across the skin. Conduction is the process of heat transfer through physical contact of one surface to another surface. Radiation is the process of heat transfer with no physical contact.

7) An older client admitted with pneumonia has a normal body temperature. What should the nurse realize as being the reason for the inconsistency in body temperature? A) The room is cold. B) The client does not have pneumonia. C) The temperature is not a valid indicator of the pathology of the illness. D) The client is losing body heat.

C Explanation: A) Older adults' temperatures may not be a valid indication of the seriousness of the pathology of a disease. Other symptoms such as confusion and restlessness may be a more accurate indicator. A decrease in temperature does not indicate that the client does not have pneumonia. The client may or may not be losing body heat. It is not known whether the room is or is not cold

4) The nurse needs to assess the body temperature of a client who has just smoked a cigarette and consumed hot coffee. Which temperature assessment method should the nurse use? A) Axillary B) Temporal artery C) Tympanic D) Rectal

C Since the oral method cannot be used because the client smoked a cigarette and consumed hot coffee, the assessment method of choice would be the tympanic membrane. This method is readily accessible and reflects the core temperature very quickly. The rectal method is inconvenient and uncomfortable for clients. The temporal artery method requires special electronic equipment. The axillary method takes a long time if an accurate measurement is to be obtained

2) During an assessment, a client who was a victim of an industrial accident has a mildly elevated body temperature. To what should the nurse attribute the client's increase in body temperature? A) Infection B) Diet C) Exercise D) Stress

D

7) While receiving report from the operating room, the nurse learns that a client's surgical wound for gallbladder removal is classified as III. What could have caused this wound classification? Select all that apply. A) The alimentary tract was not entered. B) The wound is necrotic and infected. C) Gallbladder contents spilled into the surgical site. D) A break in sterility occurred during the surgery. E) The alimentary, respiratory, genital, or urinary tract was entered.

C, D Explanation: A) An incision is classified as III-contaminated wound if gross spillage occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I-clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV-dirty, infected if the wound is necrotic and infected. An incision is classified as II-clean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.

9) A client with a burn injury is prescribed mechanical debridement of the wounds. What will the nurse plan to do when performing mechanical debridement? Select all that apply. A) Schedule the client for a homograft. B) Apply a topical agent to dissolve necrotic tissue. C) Irrigate the burn wounds. D) Apply wet-to-dry gauze dressings. E) Schedule the client for hydrotherapy.

C, D, E Explanation: A) Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement

4) The nurse is concerned that a client is at a high risk for a burn injury. What did the nurse assess in this client? Select all that apply. A) Part-time employment at a convenience store B) Diagnosis of hypertension C) Age 71 years D) Utilizes public transportation for grocery shopping E) Currently smokes 1 pack per day of cigarettes

C, E Explanation: A) Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, sense of smell, and hearing, and impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Careless smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury

8) The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status? A) Creatine phosphokinase (CPK) B) BUN levels C) Hemoglobin D) Albumin level

D Explanation: A) Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent upon the fluid status

11) A nurse instructor is educating a group of student nurses regarding heat and cold injuries. The nurse includes which correct statement regarding thermoregulation? A) "Core temperature varies widely depending on the outside environment." B) "The body's surface temperature remains relatively constant." C) "Chemical thermogenesis occurs with the increase of cortisol." D) "All muscle activity, regardless of location, produces heat

D Explanation: A) All muscle activity, regardless of location, produces heat. Core temperature remains relatively constant, whereas the body's surface temperature varies widely depending on the outside environment. Chemical thermogenesis occurs with increased thyroxine output, not cortisol

8) A client is prescribed medication for an elevated body temperature. What would be appropriate for the nurse to provide to the client? A) Muscle relaxant B) Antihypertensive C) Sedative D) Antipyretic

D Explanation: A) Antipyretic medication is used to reduce the body temperature. Antihypertensives are used to reduce blood pressure. Muscle relaxants and sedatives do not reduce body temperature

3) A client is being evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. What best describes the underlying cause for this manifestation? A) Decreased osmotic pressure in the burned tissue B) Reduced vascular permeability at the site of the burned area C) Increased fluids in the extracellular compartment D) Inability of the damaged capillaries to maintain fluids in the cell walls

D Explanation: A) Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments

10) After a skin graft procedure to the leg, a client is returned to the burn care unit. How will the nurse position the client? A) Place the client flat with the affected extremity abducted. B) Elevate the head of bed 30°. C) Maintain the head of the bed flat. D) Elevate the affected extremity

D Explanation: A) Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis

3) A client is experiencing an elevated temperature. What should the nurse include in this client's plan of care? Select all that apply. A) Administer warm intravenous fluids. B) Apply warm blankets. C) Provide dry clothing. D) Increase oral fluid intake. E) Administer antipyretic medication

D, E A) The client has an elevated temperature. The administration of antipyretic medication is one treatment used to lower the body temperature. Increasing oral fluid intake is an intervention for an elevated body temperature. The other options would be interventions to help a client with a lower body temperature.

6) The nurse is caring for a client admitted with minor burns and elevated body temperature after being in a house fire. What should be included in this client's plan of care? Select all that apply. A) Providing blankets B) Keeping the room temperature warm C) Restricting fluids D) Encouraging fluids E) Lowering room temperature

D, E Explanation: A) The client with an elevated body temperature should be encouraged to ingest fluids or should be provided with IV fluids. The increase in body temperature could be due to dehydration. Another intervention to help the client with an elevated temperature is to lower the room temperature. The client's fluids should not be restricted. Blankets and providing a warm room would be applicable if the client had a low body temperature