Exam 2 Flashcards
(125 cards)
1
Q
The nurse is caring for a patient suspected of having renal dysfunction. When reviewing laboratory results for this patient, the nurse interprets the presence of which substances in the urine as most suggestive of pathology?
A
Glucose and protein
2
Q
A nurse knows that specific areas in the ureters have a propensity for obstruction. Prompt management of renal calculi is most important when the stone is located where?
A
In the ureteropelvic junction
3
Q
A patient with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?
A
Returning bicarbonate to the body’s circulation
4
Q
A patient has experienced excessive losses of bicarbonate and has subsequently developed an acid-base imbalance. How will this lost bicarbonate be replaced?
A
Renal tubular cells will generate new bicarbonate.
5
Q
A patients most recent laboratory findings indicate a glomerular filtration rate (GFR) of 58 mL/min. The nurse should recognize what implication of this diagnostic finding?
A
The patient is likely to have increased serum creatinine levels.
6
Q
A patient is scheduled for a diagnostic MRI of the lower urinary system. What pre-procedure education should the nurse include?
A
Relaxation techniques to apply during the test
7
Q
The nurse is caring for a patient who is going to have an open renal biopsy. What would be an important nursing action in preparing this patient for the procedure?
A
Keep the patient NPO prior to the procedure.
8
Q
A nurse is working with a patient who will undergo invasive urologic testing. The nurse has informed the patient that slight hematuria may occur after the testing is complete. The nurse should recommend what action to help resolve hematuria?
A
Increased fluid intake following the test
9
Q
A patient admitted to the medical unit with impaired renal function is complaining of severe, stabbing pain in the flank and lower abdomen. The patient is being assessed for renal calculi. The nurse recognizes that the stone is most likely in what anatomic location?
A
Ureter
10
Q
The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time?
A
With each meal
11
Q
The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)?
A
The patient’s average urine output has been 10 mL/hr for several hours.
12
Q
A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patient’s care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?
A
Excess fluid volume related to generalized edema
13
Q
A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurses care of this patient?
A
The patient’s disease is incurable and the nurse’s interventions will be supportive.
14
Q
The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patient’s siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder?
A
Polycystic kidney disease (PKD)
15
Q
A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase?
A
Dehydration
16
Q
The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurse’s role in caring for this patient? Select all that apply.
A
Providing emotional support for the family, Monitoring for complications, Participating in emergency treatment of fluid and electrolyte imbalances, and Providing nursing care for primary disorder (trauma)
17
Q
The nurse has identified the nursing diagnosis of risk for infection in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk?
A
Maintain aseptic technique when administering dialysate.
18
Q
A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patient’s peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply.
A
The cuffs are made of Dacron polyester, The cuffs stabilize the catheter, The cuffs prevent the dialysate from leaking, and The cuffs provide a barrier against microorganisms
19
Q
A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?
A
Assess for a thrill or bruit over the vascular access site each shift.
20
Q
The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patients output from surgical drains, the nurse should assess what parameters? Select all that apply.
A
Quantity of output, Color of the output, and Visible characteristics of the output
21
Q
A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient?
A
Drink liberal amounts of fluids.
22
Q
The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?
A
Teach the patient to perform pelvic floor muscle exercises.
23
Q
The nurse is caring for a patient with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a patient with an indwelling catheter?
A
Empty the drainage bag at least every 8 hours.
24
Q
A nurse on a busy medical unit provides care for many patients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which patient?
A
A patient who has Alzheimers disease and who is acutely agitated
25
The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply.
Dietary history, Family history of renal stones, and Medication history
26
A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient’s post-procedure care?
Strain the patient’s urine following the procedure.
27
The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day?
2,000 mL
28
A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1F (38.4C). How should the nurse best respond to the patient?
Tell the patient to report to the ED for further assessment.
29
A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patients discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt?
Increasing fluid intake
30
The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices?
Avoid using moisturizing soaps and body washes when cleaning the peristomal area.
31
A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of disturbed body image. How can the nurse best address the effects of this urinary diversion on the patient’s body image?
Encourage the patient to speak openly and frankly about the diversion.
32
A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed?
The widest part of the stoma
33
The nurse is being trained to perform assessment screenings for abuse on patients who come into the walk-in clinic where the nurse works. Which of the following assessment questions is most appropriate?
Have you ever been forced into sexual activity?
34
The nurse is taking the sexual history of an adolescent who has come into the free clinic. What question best assesses the patients need for further information?
What questions or concerns do you have about your sexual health?
35
A nurse is collecting assessment data from a premenopausal patient who states that she does not have menses. What term should the nurse use to document the absence of menstrual flow?
Amenorrhea
36
The nurse is planning the sexual assessment of a new adolescent patient. The nurse should include what assessment components? Select all that apply.
Physical examination findings, Laboratory results, and Health history
37
A nurse presenting an educational event for a local community group is addressing premenstrual syndrome (PMS). What treatment guideline should the nurse teach this group?
Increase the frequency and intensity of exercise.
38
A patient states that PMS that is significantly disrupting her quality of life and that conservative management has failed to produce relief. What pharmacologic treatment may benefit this patient?
An SSRI
39
A 21-year-old woman has sought care because of heavy periods and has subsequently been diagnosed with menorrhagia. The nurse should recognize which of the following as the most likely cause of the patient’s health problem?
Cervical or uterine cancer
40
A couple has come to the infertility clinic because they have been unable to get pregnant even though they have been trying for over a year. Diagnostic tests are planned for the woman to ascertain if ovulation is regular and whether her endometrium is adequately supported for implantation. What test would the nurse expect to have ordered for this woman?
Serum progesterone
41
The nurse is working with a couple who is being evaluated for infertility. What nursing intervention would be most appropriate for this couples likely needs?
Referring them to appropriate community resources
42
A 48-year-old woman presenting for care is seeking information about hormone therapy (HT) for the treatment of her perimenopausal symptoms. The patients need for relief from hot flashes and other symptoms will be weighed carefully against the increased risks of what complications of HT? Select all that apply.
Breast cancer, Cardiovascular disease, and Venous thromboembolism
43
A 51-year-old woman is experiencing perimenopausal symptoms and expresses confusion around the possible use of hormone therapy (HT). She explains that her mother and aunts used HT and she is unsure why few of her peers have been prescribed this treatment. What should the nurse explain to the patient?
Research has shown that significant health risks are associated with HT.
44
The nurse is assessing a patient who believes that she has recently begun menopause. What principle should inform the nurses interactions with this patient?
The nurse must carefully assess the patient’s feelings and beliefs surrounding menopause.
45
A patient calls the clinic and tells the nurse she has thick white, curd-like discharge from her vagina. How should the nurse best interpret this preliminary data?
The patient may have a Candida species infection.
46
While taking a health history on a 20-year-old female patient, the nurse ascertains that this patient is taking miconazole (Monistat). The nurse is justified in presuming that this patient has what medical condition?
Candidiasis
47
A patient comes to the clinic complaining of a tender, inflamed vulva. Testing does not reveal the presence of any known causative microorganism. What aspect of this patient’s current health status may account for the patient’s symptoms of vulvitis?
The patient has type 1 diabetes.
48
A 14-year-old is brought to the clinic by her mother. The mother explains to the nurse that her daughter has just started using tampons but is not yet sexually active. The mother states I am very concerned because my daughter is having a lot of stabbing pain and burning. What might the nurse suspect the problem is with the 14-year-old?
Vulvodynia
49
When teaching patients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor?
HPV
50
A female patient with HIV has just been diagnosed with condylomata acuminata (genital warts). What information is most appropriate for the nurse to tell this patient?
This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.
51
A public health nurse is participating in a campaign aimed at preventing cervical cancer. What strategies should the nurse include is this campaign? Select all that apply.
Promotion of HPV immunization, Encouraging young women to delay first intercourse, Smoking cessation, and Using safer sex practices
52
A patient diagnosed with cervical cancer will soon begin a round of radiation therapy. When planning the patients subsequent care, the nurse should prioritize actions with what goal?
Protecting the safety of the patient, family, and staff
53
A 45-year-old woman has just undergone a radical hysterectomy for invasive cervical cancer. Prior to the surgery the physician explained to the patient that after the surgery a source of radiation would be placed near the tumor site to aid in reducing recurrence. What is the placement of the source of radiation called?
Brachytherapy
54
A 25-year-old patient diagnosed with invasive cervical cancer expresses a desire to have children. What procedure might the physician offer as treatment?
Radical trachelectomy
55
The nurse is caring for a patient with a diagnosis of vulvar cancer who has returned from the PACU after undergoing a wide excision of the vulva. How should this patient’s analgesic regimen be best managed?
Scheduled analgesia should be administered around-the-clock to prevent pain.
56
A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?
Most cases of ovarian cancer are considered to be random, with no obvious causation.
57
A patient is post-operative day 1 following a vaginal hysterectomy. The nurse notes an increase in the patient’s abdominal girth and the patient complains of bloating. What is the nurses most appropriate action?
Apply warm compresses to the patient’s lower abdomen.
58
A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?
Count and inspect each perineal pad that the patient uses.
59
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the women’s group to raise their arms and inspect their breasts in a mirror. A member of the women’s group asks the nurse why raising her arms is necessary. What is the nurses best response?
It will help to observe for dimpling more closely.
60
During a recent visit to the clinic a woman presents with erythema of the nipple and areola on the right breast. She states this started several weeks ago and she was fearful of what would be found. The nurse should promptly refer the patient to her primary care provider because the patient’s signs and symptoms are suggestive of what health problem?
Paget’s disease
61
A patient has presented for her annual mammogram. The patient voices concerns related to exposure to radiation. What should the nurse teach the patient about a mammogram?
Radiation from a mammogram is equivalent to an hour of sunlight.
62
A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurses best response?
An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment.
63
A patient is being discharged home from the ambulatory surgery center after an incisional biopsy of a mass in her left breast. What are the criteria for discharging this patient home? Select all that apply.
Patient must have someone to accompany her home, Patient must understand activity restrictions, and Patient must understand care of the biopsy site
64
The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
Non-tenderness
65
A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patients lump is cancerous?
A nonmobile mass with irregular edges
66
The nurse is performing a comprehensive health history of a patient who is in her 50s. The nurse should identify what risk factor that may increase this patients risk for breast cancer?
The patient gave birth to her first child at age 38.
67
A nurse has assessed that a patient is not yet willing to view her mastectomy site. How should the nurse best assist the patient is developing a positive body image?
Provide the patient with encouragement in an empathetic and thoughtful manner
68
A patient has been discharged home after a total mastectomy without reconstruction. The patient lives alone and has a home health referral. When the home care nurse performs the first scheduled visit to this patient, what should the nurse assess? Select all that apply.
Adherence to the exercise plan, Overall psychological functioning, and Integrity if surgical drains
69
A nurse is teaching a 53-year-old man about prostate cancer. What information should the nurse provide to be facilitate the early identification of prostate cancer?
Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
70
A nurse is performing an admission assessment on a 40-year-old man who has been admitted for outpatient surgery on his right knee. While taking the patients family history, he states, “My father died of prostate cancer at age 48.” The nurse should instruct him on which of the following health promotion activities?
The patient should have PSA levels drawn regularly
71
A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?
The patient should avoid close contact with his daughter for 2 months
72
A patient is 24 hours postoperative following prostatectomy and the urologist has ordered continuous bladder irrigation. What color of output should the nurse expect to find in the drainage bag?
Light pink
73
A nursing student is learning how to perform sexual assessments using the PLISSIT model. According to this model, the student should begin an assessment by doing which of the following?
Asking the patient if he is willing to discuss sexual functioning
74
A clinic nurse is providing pre-procedure education for a man who will undergo a vasectomy. Which of the following measures will enhance healing and comfort? Select all that apply.
Wearing a scrotal support garment and Using a sitz bath
75
A patient presents to the emergency department with paraphimosis. The physician is able to compress the glans and manually reduce the edema. Once the inflammation and edema subside, what is usually indicated?
Circumcision
76
A 75-year-old male patient is being treated for phimosis. When planning this patient’s care, what health promotion activity is most directly related to the etiology of the patient’s health problem?
Teaching the patient about the importance of hygiene
77
An uncircumcised 78-year-old male has presented at the clinic complaining that he cannot retract his foreskin over his glans. On examination, it is noted that the foreskin is very constricted. The nurse should recognize the presence of what health problem?
Phimosis
78
A 57-year-old male comes to the clinic complaining that when he has an erection his penis curves and becomes painful. The patient’s diagnosis is identified as severe Peyronie’s disease. The nurse should be aware of what likely treatment modality?
Surgery
79
A 35-year-old man is seen in the clinic because he is experiencing recurring episodes of urinary frequency, dysuria, and fever. The nurse should recognize the possibility of what health problem?
Chronic bacterial prostatitis
80
A 55-year-old client with a history of type 1 diabetes presents at the clinic reporting erectile dysfunction. The physician prescribes tadalafil to be taken 2-hour before sexual intercourse. The nurse reviews the client’s history prior to instructing the client on the use of this medication. What disorder will contraindicate the use of tadalafil?
Retinopathy
81
Following a recent history of dyspareunia and lower abdominal pain, a client has received a diagnosis of pelvic inflammatory disease (PIDS). When providing health education related to self-care, the nurse should address what topics? Select all that apply.
Use of condoms to prevent infecting others and Appropriate use of antibiotics
82
When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?
The palms of the hands
83
A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin?
D
84
An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many spots on her skin., what would be an appropriate response by the nurse?
As people age, they normally develop uneven pigmentation in their skin
85
A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?
By protecting older adults against shearing injuries
86
A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?
Diminished protection of tissues and organs
87
A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion?
Pustule
88
A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?
Wheal
89
Assessment of a patient’s leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
Ulcer
90
A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (Warfarin). For what skin lesion should the nurse monitor this patient?
Ecchymosis
91
The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?
Cherry angiomas
92
A nurse is assessing the skin of a patient who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the patient’s health history, the nurse should identify what comorbidity as increasing the patient’s vulnerability to skin infections?
Diabetes
93
A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction?
Moderately positive
94
A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen?
Patch testing
95
A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What should be the most appropriate question to ask this patient and her family?
Has she eaten any new foods today?
96
A patient presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition?
Tzanck smear
97
A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risks of basal cell carcinoma (BCC)?
Teaching participants to limit their sun exposure
98
A patient presents at the free clinic with a black, wart-like lesion on his face, stating, I’ve done some research, and I’m pretty sure I have malignant melanoma. Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis?
The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable
99
While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patient’s ear. The nurse knows that this lesion is consistent with what type of skin cancer?
Malignant melanoma
100
A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include?
Deficient Knowledge about Early Signs of Melanoma
101
A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment?
Wide excision
102
A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?
Anticipate the need for, and administer, appropriate analgesic medications
103
A nurse educator is teaching a group of medical nurses about Kaposis sarcoma. What would the educator identify as characteristics of endemic Kaposis sarcoma? Select all that apply.
Affects people predominantly in the eastern half of Africa, Affects men more than women, and Can progress to lymphadenopathic forms
104
A nurse is providing care for a patient who has developed Kaposi’s sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body?
Endothelial cells lining small blood vessels
105
A 35-year-old kidney transplant comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposis sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposis Sarcoma?
Immunosuppression-related
106
A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse expect?
Classic Kaposis sarcoma
107
A 30-year-old male patient has just returned from the operating room after having a flap done following a motorcycle accident. The patient’s wife asks the nurse about the major complications following this type of surgery. What would be the nurses best response?
The major complication is when the blood supply fails and the tissue in the flap dies
108
A patient comes to the dermatology clinic requesting the removal of a port-wine stain on his right cheek. The nurse knows that the procedure especially useful in treating cutaneous vascular lesions such as port-wine stains is what?
Laser treatment
109
A client with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?
Surgical excision
110
A nurse practitioner is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?
Benzoyl Peroxide and erythromycin (Benzamycin)
111
A patients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?
Lactated Ringers
112
The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care?
Acute
113
A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?
Prevention of venous thromboembolism
114
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?
That’s something that you and your doctor will likely talk about after your scars mature
115
A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member?
His body has consumed his fat deposits for fuel because his calorie intake is lower than normal
116
A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
Continuously
117
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?
That’s something that you and your doctor will likely talk about after your scars mature
118
Your older adult patient has been diagnosed with urosepsis and has a temperature of 103.4F. you should be aware that the oxygen demands of the patients body would change in which direction and why?
Increase due to an increase in metabolism
119
The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk?
Encourage physical activity and range of motion exercises
120
A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?
Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream
121
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
Assess the patients peripheral pulses distal to the dressing
122
A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?
Apply a layer of ointment approximately 1/16 inch thick
123
A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response?
Inform the primary care provider promptly because the graft may need to be removed
124
A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What should the nurse in the ED receiving the call instruct the father to do?
Immerse the child in a cool bath
125
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
