PT 4

50問 • 1年前

問題一覧

A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)

Cool, moist compresses, Tepid bath with cornstarch

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client?

Wash your hands on entering the clients room.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?

Change gloves between wound care on different parts of the clients body.

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?

Sometimes I wake up at night and smoke.

A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond?

You will not look exactly the same but cosmetic surgery will help.

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?

I will bathe and dress before breakfast.

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury?

It is normal to feel some depression.

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first?

Apply oxygen and continuous pulse oximetry.

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond?

It helps prevent stomach ulcers, which are common after burns.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?

Auscultate breath sounds over the trachea and bronchi.

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?

Administer furosemide (Lasix) 40 mg IV push.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately?

Serum potassium: 6.5 mEq/L

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next?

Place the client in an upright position.

A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond?

When all of his burn wounds have closed.

A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy?

Creatinine

A nurse caresfor a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain?

Administer the prescribed intravenous morphine sulfate.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?

Draw blood for a carboxyhemoglobin level.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching?

I will demonstrate how to change your wound dressing for you and your family.

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take?

Gather appropriate equipment and prepare for an emergency airway.

A nurse uses the rule of ninesto assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns?

27%

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?

Urine output of 20 mL/hr

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity?

Keep the water temperature constant when showering the client.

A nurse reviews the following data in the chart of a client with burn injuries: Based on the data provided, how should the nurse categorize this clientsinjuries?

Full thickness

After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Based on the documented data, which action should the nurse take next?

Prepare to obtain blood and wound cultures.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.)

Administer analgesics., Prevent wound infections., Provide fluid replacement.

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)

Music as a distraction, Tactile stimulation, Increasing client control

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.)

Provide at least 5000 kcal/day., Administer a diet high in protein., Collaborate with a registered dietitian, Offer frequent high-calorie snacks.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.)

Slower healing time Increased risk for loss of function from contracture formation, Reduced thoracic compliance Increased risk for atelectasis, High incidence of cardiac impairments Increased risk for acute kidney injury

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to preven infection in the client? (Select all that apply.)

Ask all family members and visitors to perform hand hygiene before touching the client., Carefully monitor burn wounds when providing each dressing change., Use aseptic technique and wear gloves when performing wound care.

A patient had a deep skin biopsy. Which response to the patient's concern about postprocedure care is correct?

"An appointment will be made for you to return for suture removal."

Which general term is used to document a wound, sore, tumor, or other tissue damage?

Lesion

An older adult patient is admitted to the hospital with multiple large, purplish bruises on the arms. When questioned further, the patient states "these happen when I barely bump into something". Which term is accurate when documenting these lesions?

Senile purpura

A patient presents for a shave biopsy of a skin lesion on the shoulder. Which type of excision is done with this procedure?

Specimen obtained from the dermis with a scalpe

A patient presents with a Stage 3 pressure ulcer to the sacrum. The wound has a large amount of exudate. Which type of dressing would be utilized for this type of wound?

Absorptive

Which intervention is the most important when preparing to change a dressing on a patient with negative pressure wound therapy?

Medicate the patient about 1 hour before the procedure.

The LVN/LPN is conducting an assessment on a patient with anxiety and notes that the patient has white lips, mucous membranes, and nail beds. Which term is used to document this assessment?

Pallor

An older adult patient is complaining about her wrinkled skin. Which explanation regarding this occurrence is correct?

This is caused by thinning of the skin and degeneration of elastin fibers.

Which topical medication will be applied to a patient with a minor skin infection?

acitracin and polymyxin B (Polysporin)

The nurse is determining the presence of jaundice in a dark-skinned patient. Which areas would be observed to assist in the visual evaluation? (Select all that apply.)

Soles of feet, Conjunctivae, Oral mucous membranes, Palms of hands

An obese patient is admitted with intertrigo between the abdominal skinfolds. The physician treats the patient for the presence of C. albicans. Which interventions are used for this condition?

Apply antifungals and corticosteroids as ordered.

A patient reveals the use of angelica as an alternative therapy. Which instruction should the nurse provide for this patient

he agent can cause a skin rash if a patient is exposed to sunlight.

A woman of childbearing age is to begin taking Soriatane. Which instructions should the patient receive concerning this medication?

Use reliable contraception during therapy and for 3 years after therapy with Soriatane

The nurse is caring for a patient who sustained a burn injury 1 week ago and has been transferred to the nursing unit. The patient has a bounding pulse and hypertension. Which condition would this signify?

Fluid volume excess

For which purpose is ketoconazole (Nizoral) used when ordered for a patient?

To treat a fungal infection

For which condition are patients who are pregnant, malnourished, immunosuppressed, or taking antibiotics at risk?

Candidiasis

A patient is being treated with intravenous amphotericin B for a severe fungal infection. To which body system is this drug treatment toxic?

Renal

The nurse is working in the postoperative area and just received a patient recovering from a blepharoplasty. For which possible complications should the nurse monitor? (Select all that apply.)

Hematoma, Corneal injury

Which descriptions are accurate about basal cell carcinomas? (Select all that apply.)

Pearly appearance, Treated with surgical excision, Related to sun exposure

A nurse stops to give first aid to a burn victim who is seen running from a home. The victim's clothing is on fire. What action is the nurse's immediate priority?

Roll the victim to smother the flames.

The nurse notes that the victim's chest and neck are burned. What nursing action is most appropriate at this time?

Monitor the client for respiratory distress.

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ユーザ名非公開 · 61問 · 1年前

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