(Q's) from (Iggy, Pharm Success, NLEX, Medsurg success and AEQ)
Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatment?
(C) the medication will permanently stain my skin does not stain the skin
A client reviewing parenteral nutrition suddenly develops a fever. The nurse notifies the HCP and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued material?
(C)Send them to lab for culture
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response?
(C)The graft will come from an animal, probably a pig.
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." Which initial response by the nurse is best?
(D) "I know you're worried, but it is too early to tell how much scarring will occur."
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?
(D) 100% oxygen via a tight-fitting, nonrebreather face mask
The nurse caring for a client with sepsis writes the client disposes of "alteration in comfort R/T chills and fever. Which intervention should be included in the plan of care?
(D) Administer an antipyretic medication every four (4) hours PRN.
What should the nurse include in the discharge instructions for a client who will be receiving total parenteral nutrition (TPN) at home?
(D) Administering the TPN while working around the client's normal activities
Following kidney transplantation, cyclosporine (sand immune) is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?
(D) Elevated Blood urea nitrogen levels
The nurse is caring for a client who sustained superficial partial thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?
(D) Elevated hematocrit levels
The client with an electrical burn is brought to the ED. The entrance wound is on the right hand and the exit wound is on the left foot. Which intervention should the nurse implement?
(D) Place the client on cardiac telemetry
When preparing discharge teaching for a client who had a kidney transplant, in addition to a corticosteroid, the nurse expects what other medications to be prescribed to prevent kidney rejection?
(D) Tacrolimus and mycophenolate mofetil
The nurse is preparing to change the PN solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change?
(D) Take a deep breath, hold it and bear down this helps to eliminate air embolism
The nurse received the am shift report on the following clients. Which client should the nurse assess first?
(D) The client who has full-thickness burns who needs to be medicated before being taken to whirlpool
The nurse is caring for a client with deep partial thickness and full thickness burns to the chest area. Which assessment data would warrant notifying the HCP?
(D) The client's urinary output is 50 mL in two hours
The burn client asks the nurse not to remove the loosened bits of skin and tissue during the dressing change, saying "The more skin you take off the longer it will take to heal." What is the nurse's best response ?
(D) This tissue is no longer living and as long as it is present, real healing can not occur
A client is receiving PN. The nurse monitors the client for complications of the therapy and should assess the client for which manifestations of hyperglycemia?
(D) Weakness, thirst and increased urine output
A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides what benefit?
(D) Will meet the client's nutritional needs without causing the discomfort precipitated by eating
A client receiving PN in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition?
(D) crackles on auscultation of the lungs
A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock should the nurse monitor for in this client?
(D) hypovelemic
To begin the administration of total parenteral nutrition (TPN), a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing action?
(B) Auscultate the lungs to evaluate breath sounds.
A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication?
(B) Place the medication directly on the burn wound in a thin layer using sterile gloves.
The nurse is making initial rounds at the beginning of the shift and notes that the PN bag of an assigned client is empty. Which solution readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered?
(B) 10 % dextrose in water The client is at risk for hypoglycemia
The nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit. The nurse understands that which client would be the least likely candidate for PN?
(B) A 42 year old client who has had an open cholecystectomy
Which client should the nurse use caution when applying mafenide acetate (sulfamylon), a topical antimicrobial agent, to a burned area?
(B) A client with COPD Sulfamylon impairs the renal mechanism involved in the buffering of the blood, thereby increasing the excretion of bicarbonate in the urine. When this occurs, the pulmonary system effects a compensatory hyper ventilatory status to maintain normal acid-base balance. If this compensation cannot take place as a result of pulmonary disease, the client develops metabolic acidosis
A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data?
(B) Urine output every hour
A client is being weaned from parenteral nutrition and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription?
(B) decrease the PN rate to 50 mL per hour
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, an (NSAID), presents to the ED with abdominal pain, is pale and clammy and has a pulse of 110 and BP 92/60. Which type of shock would the nurse suspect?
(B) hypovolemic
The client is admitted into the ED with diaphoresis, pale clammy skin, and BP of 90/70. What intervention should the nurse implement first?
(B) start an IV with an 18 gauge Cath
A client is waiting for a kidney transplant. What explanation should the nurse include when teaching the client about the transplant?
(B) you will require immunosuppressive drugs daily for the rest of your life.
The nurse is teaching a group of community members about fire safety. A participant asks, "what should I do if I get hot grease on my hand?" Which statement is the best response by the nurse
(B)"Place the hand under cool tap water"
A client is brought to the ED with partial thickness burns to his face, neck, arms and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.
(B)Assess airway for potency (C)Administer Oxygen as prescribed (E)Elevate extremities if no fractures are present
A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply.
(B)Brassy cough (D)Singed nasal hair (E)dark mucous membrane
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) after extensive colon surgery. The nurse concludes that the client understands teaching about the purpose of TPN when the client makes which statement?
(C) "TPN provides total nutrition when gastrointestinal function is questionable."
Which newly admitted client does the nurse consider to be at highest risk for development of sepsis?
(B) 68 year old woman 2 days post-operative from bowel surgery
The client sustained a hot grease burn to the right hand and calls the ED. Which information should the nurse provide the client?
(B) place the hand in cool water
A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock?
A. Arteriolar constriction occurs.
A client is burned on the anterior part of both legs, from the knees to the feet. The nurse uses the rule of nines to assess the percentage of total body surface area (TBSA) burned. Which percentage should the nurse document in the client's hospital record?
(A) 9%
A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which initial physiologic change will the nurse expect?
(B) An increase in serum potassium
Which intervention is most likely to decrease mortality in the septic client?
(B) Antibiotics
The nurse is caring for a client diagnosed with full-thickness burn over the right lower extremity. Which task should the nurse delegate to the UAP?
(B) Ask the UAP to cleanse the client's dentures and place in the container
The client is diagnosed with neurogenic shock. which signs and symptoms should the nurse assess in this client?
(B) Bradycardia
Which nursing action is essential prior to initiating a new prescription for 500. mL of fat emulsion (lipids) to infuse at 50 mL/hour?
(B) Determine if the client has an egg allergy
Which assessment does the nurse perform first on the client just admitted after an electrical injury with contact sites on the left hand and left foot?
(B) Electrocardiography
The nurse is providing dietary instructions to a client who has been prescribed cyclosporine (sanimmune). Which food item should the nurse instruct the client to exclude from their diet?
(C) Grapefruit juice
A client receiving PN complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention and crackles bilaterally. The nurse determines that the client is experiencing which complication?
(C) Hypervolemia
A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report?
(D) 36
The client with a partial-thickness burn to the right arm is prescribed mafenide acetate (Sulfamylon), a topical antimicrobial. Which intervention should the ED nurse implement when applying the medication?
(D) Premeditate the client This medication causes pain or a burning sensation following its application; therefore, the client should be premedicated
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?
(D) Restoring fluid volume
Why are the manifestations of most types of shock the same regardless of what specific events or conditions cause the shock to occur?
(D) The sympathetic nervous system is triggered by any type of shock and initiates the stress response
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which lab data requires the nurse to notify the HCP?
(D) the clients culture and sensitivity is resistant to the clients antibiotics
A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis?
A. Cold, Clammy skin
Which symptoms does the nurse recognize that may indicate a pulmonary injury from the inhalation? Select all that apply.
A. Development of a brassy cough B. Drooling D. Audible wheeze The degree of inhalation damage depends on the fire source, temperature, environment, and types of toxic gas generated. Black particles of carbon in the nose, mouth, and sputum indicate smoke inhalation. A change in respiratory pattern may indicate damage if the patient becomes progressively hoarse, develops a brassy cough, has difficulty swallowing, or drools and produces sounds on exhalation that include an audible wheeze, crowing, or stridor.
A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply.
A. Fever B. Tachypnea D. Abdominal rigidity
A patient arrives to the ED with superficial facial burns from an explosion. The patient has productive carbonaceous sputum with labored respirations and singed facial hair. Based on these findings, what is the highest priority of care for this patient?
B. Assessing airway patency The priority concern with this patient is the airway. An emergency assessment should first be completed. The productive carbonaceous sputum with labored breathing and singed hair is a sign of inhaled exposure and smoke inhalation. Knowledge of the circumstances causing the burn is valuable in the management of a burn victim. Continuous airway assessment is a nursing priority. The emergency physician will be there to assist the nurse during this critical period. A full assessment should be performed after the initial emergency assessment is completed.
The client is being discharges after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health?
C. Tell the client to remember that changes in lifestyle take time The client needs to know that it will take time to adjust to life after a burn injury and that returning to work, family role, sexual intimacy, and body image will take time. The client should resume previous activities gradually and should not stay home. The client should be honest with self, family, and friends about needs. The client should feel free to discuss feelings with family friends, and the therapist.
A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure the nurse can instruct the person to apply before seeking healthcare?
(A) cool, moist towelettes
The client with partial and full thickness burns to 35% of the body is admitted to the burn department. The HCP has prescribed famotidine (Pepcid), a histamine2 antagonist. Which statement best describes the scientific rationale for administering this medication?
(D) Pepcid will help decrease gastric acid production Curling's ulcer (stress ulcer) is an acute ulceration of the stomach or duodenum that forms following a burn injury. Histamine2 antagonists like Pepcid are administered to decrease gastric acid recreation in the acute phase of burn care
A client with MI is developing cariogenic shock. Because of the rise of myocardial ischemia, what condition should the nurse carefully assess the client for?
(2) Ventricular dysrthythmias
An adult client is receiving lactated Ringer (LR) solution for burns to the genitalia. Which percentage will the nurse calculate for total body surface area (TBSA) burned?
(A) 1%
The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings?
16 mmHg
A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition?
A failure of the circulatory pump
A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply.
A. Tachy B. Restlessness D. Decreased urine output
A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure?
D. Left ventricular functioning
A burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?
(A) hyperventilation
The nurse is caring for a client who experienced a full-thickness burn to 65% of the body 12 hours ago. After establishing a patent airway, which nursing intervention is priority for the client?
(A) Replace the clients fluids and electrolytes this prevents irreversabe shock
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?
(A) Return of distal pulses
What action by the UAP warrants intervention by the nurse?
(A) The UAP decreases the IV rate of the client whose TPN is almost empty
Which statement made by the client who experienced burns to the head and neck indicates positive adjustment to the injury?
(A) I am planning on cutting the grass in the mornings when the sun isn't as strong
Which nursing task should be delegated to the UAP for the client with a full-thickness burn over the right leg?
(A) Instruct the UAP to take the clients pulse ox reading
The nurse assesses the wound of a client burned as a result of stepping into the bath filled with hot water, which assessment finding of the burned areas on the tops of the feet does the nurse use as a basis to document a probable full-thickness burn?
(d) Thrombosed blood vessels are visible beneath the skin surface
The male client is admitted to the burn unit after a boiling pot of hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should be documented?
(deep partial thickness burn)
The nurse is monitoring the status of a clients fat emulsion infusion and notes that the infusion is 1 hour behind. Which action should the nurse take?
(C) insure that the fat emulsion rate is infusing at the prescribed rate
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. which measure should be insisted before the transfer?
(D) Ensure adequate peripheral circulation to both feet.
The nurse is changing the central line dressing of a client receiving PN and notes that the catheter insertion site appears reddened. The nurse should next assess which item?
(A) Client's temperature
The nurse is caring for a client with sepsis who is hemodynamically stable. The client is complaining of abdominal pain. Which of these primary health care provider prescriptions should the nurse do first?
(A) Draw peripheral blood cultures.
A client with PN infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position?
(A) On the left side with the head lower than the feet
The client is prescribed silver sulfadiazine (Silvadene) a topical antimicrobial agent, for a partial thickness burn to the back. What information should the nurse discuss concerning this medication?
(A) Encourage the client to drink 3000 mLs of water The client should drink large amounts of fluids to prevent sulfa crystals from forming in the urine
A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply.
(A) Pallor (B) Agitation (C) Tachy (D) Narrowing pulse pressure
The client is admitted with full-thickness burns and partial-thickness burns to more than 30% of the body. The nurse is concerned with the clients nutritional status. What intervention should the nurse implement?
(A) Encourage the client's family to bring favorite foods
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. What client problem has priority?
(A) High risk for infection
The nurse is reviewing the laboratory results for a client receiving tacrolimus (Prograf). Which lab result would indicate to the nurse that the client is experiencing an adverse effect of the medication?
(A) Blood glucose of 200 mg/dl
A client with burns over 35% of the body reports chilling. Which action will the nurse take to promote client comfort?
(A) Limit room drafts.
The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion?
(A) Oliguria
A client is admitted to an ED with chest pain that is consistent with MI based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the clients chart below. The nurse should alert the HCP because these changes are most consistent with which complication?
(A) Cardiogenic shock
The nurse in the ED administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement?
(C) have the client wait for 30 minutes
What is the most important test the nurse should check to determine whether a transplanted kidney is functioning?
(C) serum creatinine
A client who sustained serious burns now has a stress ulcer. Which clinical indicators of shock should the nurse immediately report to the primary healthcare provider? Select all that apply.
(A)Weakness (B)diaphoresis (C)tachy (D)cold extremities
The client is admitted to the ED with a partial and full thickness burn to the left leg. Which question is most important for the nurse to ask the client?
(A) "When was your last tetanus shot?" A tetanus toxoid is administered IV early in the acute phase of burn care to prevent Clostridium retain infection. If the client has not had a tetanus shot within the last 10 years or if the time is in doubt, a booster of tetanus toxoid should be administered
The client who tripped while carrying an open kettle of hot water received scald burns to the entire chest, the entire anterior section of the right arm, the right half of the abdomen, and the anterior portion of the right leg from the groin to the knee. At what percent of total body surface area does the nurse calculate the injury using the rule of nines?
(A) 22% to 23%
A week after kidney transplantation, a client develops a temperature of 101 F, the BP is elevated and the kidney is tender. The x-ray indicated that the transplanted kidney is enlarged, Based on these findings, the nurse suspects which complication?
(A) Acute rejection
The client with 45% burns has a hematocrit of 52% 10 hours after the burn injury and 6 hours after fluid resuscitation was started. What is the nurse's best action?
(A) Assess the clients BP and urine output
A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN) via an infusion pump. What is most important for the nurse to do when administering TPN?
(A) Change the TPN solution bag every 24 hours, even if there is solution left in the bag.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority?
(A) Replace fluid and electrolytes
The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output and cool, pale skin. Which phase of septic shock is the client experiencing?
(A) The hypodynamic phase The hypodynamic phase is the last and irreversible phase of shock characterized by low cardiac output with vasoconstriction
The nurse is administering medication to the client with a third degree burn on the chest area. Which medication requires a lab test?
(A) The vancomycin medication
Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is effective?
(A) Urine output increases from 5 mL/hr to 25 mL/hr
A client is to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is most important for the nurse to obtain?
(A) infusion pump
Which nursing interventions should be included for the client who has full-thickness and deep partial thickness burns to 50 % of the body. Select all that apply.
(A) perform meticulous hand hygiene (B) screen visitors for infection (E)administer prophylactic antibiotics
What nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply
(A) perform meticulous hand hygiene (B)Use sterile gloves for wound care (C) Wear gown and mask during procedures (E)Administer antibiotics are prescribed
The nurse and an UAP are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?
(A) the client places a urine specimen in a biohazard bag in the hall way
The client with a full-thickness burn over 38% of the body is admitted to the burn unit 4 hours after the fire. The HCP writes an order for lactated ringers 450 mL/hour. Which interventions should the nurse implement? Select all that apply.
(B) Administer IV fluids as prescribed (C) Infuse the IV fluids via pump -There are formulas that are used to determine the clients fluid-flume resuscitation. The formulas specify the total amount of fluid that must be infused in 24 hours, 50% in the first 8 hours followed by the other 50% over the next 16 hours. This is a large amount of fluids but is not uncommon with a patient who has full-thickness burns more than 20% of their total body surface. -The IV fluids must be infused by a pump to ensure the client recieves the correct amount for fluid resuscitation
The nurse writes the nursing diagnosis "impaired skin integrity related to open woulds" Which intervention would be appropriate fir this nursing diagnosis?
(B) Clean the client's wounds, body and hair daily.
The client with a partial-thickness burn to the entire right leg who is being treated with silver sulfadiazine (Silvadene), a sulfonamide antibacterial agent, develops leukopenia. Which medication should the nurse suspect the healthcare provider will prescribe?
(B) Continue administering the Silvadene ointment Many clients develop marked leukopenia in response to Silvadene. The leukopenia will improve spontaneously over the course of treatment. Leukopenia does not contraindicate the use of this medication.
The client comes into the ED in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin and both feet are edematous. which depth of burn should the nurse document?
(B) Deep partial thickness
A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first?
(B) Evaluate whether the client has inhaled smoke.
The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?
(B) Flushing
A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take?
(B) Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag
The nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction?
(B) Hoarse quality to the voice
The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority?
(B) Initiate IV antibiotic therapy
The client is admitted to the ED with a third-degree burn over the front of both legs. Which priority intervention should the nurse implement?
(B) Insert two large-bore intravenous access routes
The nurse is providing postoperative care to a kidney transplant recipient. What is the nurse's first priority during this period?
(B) Maintaining fluid and electrolyte balance
A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect?
(B) Metabolic acidosis
The client with burns to the head, neck and upper body from a house fire starts drooling uncontrollably about 8 hours after the injury. What is the nurse's best first action?
(B) Notify the Rapid Response Team
The nurse is preparing to hang fat emulsion and notes that fat globules are visible at the top of the solution. The nurse should take what action?
(B) Obtain a different bottle of solution
The nurse is developing care for a client who experienced full-thickness burns and deep partial thickness burns over half of the body 4 days ago. Which problem is the priority?
(B) Pain
A nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the healthcare provider should the nurse question?
(B) Potassium
The nurse is preparing to ambulate the client with full-thickness burns on the lower extremities down the hall. Which priority intervention should the nurse implement?
(B) Put a gait belt around the clients waste
A nurse is caring for a client who had a kidney transplant. Which test is most important for the nurse to monitor to determine whether a client's newly transplanted kidney is working effectively?
(B) Serum creatinine
A client is discharged from the hospital after receiving a lung transplant. Which medical device should the client use to monitor his or her lung function at home?
(B) Spirometry
A client on medication for transplant rejection is admitted with hypertension, nephrotoxicity, and gingival hyperplasia. Which medication might have caused this? Select all that apply.
(B) Tacrolimus (D) Cyclosporine
A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet?
(B) Tea
A client has been discharged to home on PN. With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy?
(B) Temperature and weight
The nurse is caring for a client with a deep partial-thickness and full-thickness burn to the chest area. Which of the following assessment data warrant notifying the healthcare provider?
(B) The client's pulse ox reading is 90%
The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?
(B) Urine output
An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior Half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing sub sequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of 9s, what would be the extent of the burn injury?
(C) 36%
A client is receiving total parenteral nutrition. The nurse assesses for which client response that indicates hyperglycemia?
(C) A fruity odor to the breath
The nurse is caring for a client diagnosed with septic shock. Which assessment data would warrant immediate intervention by the nurse?
(C) A urinary output of 90 mL in the last four hours
The client has recently experienced a MI. Which action by the nurse helps prevent cariogenic shock?
(C) Administer oxygen via nasal cannula
The nurse is discussing the application of silver nitrate, an antimicrobial agent, to a client with a partial-thickness burn to the left-leg. Which information should the nurse teach the client when discussing how to apply this medication after discharge?
(C) Apply the silver nitrate to the wound dressing every 2 hours Silver nitrate is used as a 0.5% solution in distilled water and should be applied to the bulky gauze dressing every 2 hours, and the dressing should be changed twice a day
During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1 mg/dL (260 mcmol/L). What should the nurse do first in response to this laboratory result?
(C) Assess for decreased urine output.
A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained?
(C) Electrical burn
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?
(C) Flaccid paralysis
The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?
(C) Immobilization of the affected leg
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50, a pulse rate of 110 and a urine output of 20 mL over the last hour. The nurse reports the findings to the HCP and anticipates which prescription?
(C) Increasing the amount of IV lactated Ringer's solution administered per hour
Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. The nurse should take which most appropriate action?
(C) Inform the client that this is expected
During the administration of total parenteral nutrition (TPN), an assessment of the client reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention?
(C) Interrupt the client's infusion and notify the healthcare provider
The HCP Prescribed morphine 2-5 mg IM every 2 hours for the client with full-thickness burns to the chest and abdominal area. The client reports pain of 10 on a pain scale from 1-10. Which intervention should the nurse implement?
(C) Request a PCA pump for the client The client should have IV pain medication until hemodynamically stability and unimpaired tissue perfusion return. The PCA pump provides an IV route, and the client can control the amount of medication administered with the PCA, ensuring safe limits of pain medication
The nurse is caring for a restless client who is beginning nutritional therapy with PN. The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury?
(C) Secure all connectionism the PN system
A healthcare provider in the emergency department identifies that a client is in cardiogenic shock. Which type of drug does the nurse anticipate will be prescribed?
(C) Sympathomimetic
The RN is teaching a group of new UAPs about burn care. which information regarding skin care should the RN emphasize ?
(C) Tell the UAPs to turn the client from side to side at least every 2 hours
The client is being discharged after being in the burn unit for 6 weeks. Which strategies should the nurse identify to promote the clients mental health?
(C) Tell the client to remember that changes in lifestyle take time
The nurse is caring for clients on the burn unit. After the shift report, which client should the RN see first?
(C) The client with full-thickness burns on the chest who is having difficulty breathing
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment finding requires immediate attention by the nurse?
(C) The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20
The client experience an electrical burn that resulted in full-thickness burns to the right and left hand. The HCP ordered the fluid resuscitation rates. Which data indicated the fluid resuscitation is effective?
(C) The clients output is 75-100 mL per hour The client with an electrical burn should have a urine output of 75-100 ml for fluid resuscitation to be successful
A burned client newly arrived from an accident scene prescribed 4 mg of morphine sulfate intravenously. What is the most important reason the nurse administers the analgesic to this client by the intravenous (IV) route?
(C) The danger of an overdose during fluid remobilization is reduced
The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?
(C) Wearing gloves and a gown only when giving direct care to the client
The nurse is preparing to hang the first bag of PN solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution?
(C) electronic infusion pump
During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what?
A. Metabolic acidosis
Twenty minutes later, assessment of the patient reveals loud wheezing on exhalation. What is the nurse's best action at this time?
B. Apply O2 and call the RRT Manifestations such as wheezing, crowing, or stridor may mean that the patient is about to lose his airway. Immediately apply oxygen and call the Rapid Response Team. The patient may need to be intubated before his airway becomes obstructed.
A client is brought to the emergency department by an emergency medical services (EMS) squad after being burned with unknown chemicals. The client's body is covered with a white, powdery substance, and the client cries out, "Get this stuff off me! It's burning me!" Which action by the nurse would be first?
B. Brush the substance off the client and remove clothes Do not wet the chemicals on skin or clothing; brush off the chemicals and then remove the client's clothing. The next steps would be start an IV line to administer analgesics and contact poison control to identify the chemical.
The nurse is caring for a patient who is admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care?
B. Evaluate airway and circulation Initial management of a burn-injured patient focuses on assessing the patient's airway, breathing, and circulation. Other priorities include keeping the patient warm, elevating extremities to reduce edema, preparing for fluid resuscitation, estimating the total body percent of burn injury, and administering tetanus toxoid prophylaxis.
A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care?
B. The body initially attempts to compensate by maintaining peripheral vasoconstriction.
A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe?
C. Blood replacement
A nurse is precepting a senior-level nursing student. The preceptor knows the nursing student understands the concept of screening for sepsis when the student makes what statement?
D. "Sepsis mortality is affected greatly by treatments performed in the first 6 hours."
