Week 14 - PrepU Transplant & Burn Questions
The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?
Intravenous
The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching?
- contact the primary provider if the garment does not seem to fit properly - massage any moisturizers, lotions, creams and petroleum-based ointments completely into the skin before donning the garmnet
The nurse is caring for a client with a history of a renal transplant who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the client asks, "Will this chronic infection hurt my new kidney?" What should the nurse know about chronic rhinosinusitis in this client?
Taking immunosuppressive drugs can contribute to chronic rhinosinusitis.
The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply. - oxygen saturation - heart rate - urine output - blood pressure
- heart rate - urine output
The nurse is caring for a client with burns over 55% of total body surface area. Which information is essential for the nurse to document to guide the care of this client?
- pre-burn body weight - current list of medications - last tetanus immunization - current body temperature
A nurse is providing discharge teaching for a client with a burn wound on the leg. What instructions are important to give the client?
- report increased redness and wound drainage to healthcare provider - wash wound with soap and water - continue physical therapy exercises
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn?
- wrap cool towels around the affected extremity intermittently
The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply. - no brain waves - absence of brainstem reflexes - coma - apnea
- absence of brainstem reflexes - apnea - coma
The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. - absence of pain response - apnea - absence of deep tendon reflexes - coma - absence of brainstem reflexes
- apnea - coma - absence of brainstem reflexes
The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation?
Establish a patent airway.
An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?
Administer IV fluids.
A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation?
Airway management
When a patient is taking an immunosuppressant following heart transplantation, the nurse would determine what as the MOST important intervention?
Assess vital signs every 4 hours.
A client with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the client's prioritization for receiving a donor liver be determined?
By objectively determining the client's medical need
Which complication is common for victims of electrical burns?
Cardiac dysrhythmias
What quick assessment technique should the nurse use to assess the percentage of burn injury?
Compare the client's palm with the size of the burn wound **palm is about 1% of a person's TBSA
The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings?
Contact the primary care provider and prepare for an escharotomy.
A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the best determination that the brain's electrical activity has ceased?
Electroencephalography (EEG)
A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care?
Fluid status
A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: - Glasgow Coma Scale of 6 - Apnea - Absence of brainstem reflexes - Coma
Glasgow Coma Scale of 6
What changes occur to the heart as a result of heart transplant?
Heart beats faster than the natural heart
A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event?
Hemodynamic instability
What term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?
Herniation
A triage nurse in the emergency department (ED) receives a phone call from a frantic parent who saw their 4-year-old child tip a pot of boiling water onto themselves. The parent has called an ambulance. What should the nurse in the ED receiving the call instruct the parent to do?
Immerse the child in a cool bath.
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?
Immunosuppressive agents
A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. What s/s indicate approaching death?
Loss of brain stem reflexes
A client with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this client?
Meticulous infection control precautions
A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client?
Presence of soot around nasal passages
What does a nurse have to assess during the bone marrow transplant (BMT) procedure?
Psychological status
The nurse is providing education to a client that is scheduled for mechanical débridement of a wound. The nurse knows that mechanical débridement involves which element?
Removal of eschar until the point of pain and bleeding occurs
The nurse is caring for a 21-year-old client with a diagnoses of brain death due to injuries sustained in a snowboarding accident. The family has chosen to remove life support measures to allow the client's death. Upon hearing the family's decision, what is the nurse's first action?
Request senior medical staff discuss organ donation
A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. What most likely would be ordered?
Tacrolimus
A nurse is planning the care of a client who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this client?
Thorough and consistent hand hygiene
A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood?
The client is likely experiencing a delayed onset of respiratory complications
An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury?
The total body surface area (TBSA) affected by the burn
In what response do T lymphocytes have a role?
Transplant rejection
A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
acute pain