Nokea
The greatest threat during the immediate post-burn period results from burn shock. Which of the following statements best describes why burn shock occurs?
- A. Damaged tissues release histamine and other substances that can result in vasodilatation and increased capillary permeability with a loss of fluid from the vascular compartment to the interstitial space.
- B. Large amounts of fluid are lost from the burn site, which results in a decrease in circulating volume.
- C. Large amounts of epinephrine are released, leading to severe vasoconstriction and shock.
- D. Release of epinephrine leads to tachycardia, ineffective cardiac output, and shock.
Correct Answer: A
Rationale: Burn shock occurs due to histamine release causing vasodilation and increased capillary permeability, leading to fluid loss from the vascular to interstitial space.
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An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture.
- A. What is the most important nursing care plan inclusion for an elderly client post-femoral fracture repair?
- B. Eat a high-protein, low-residue diet.
- C. Lie on her unoperated side.
- D. Exercise her arms and legs.
- E. Cough and deep breathe.
Correct Answer: D
Rationale: Coughing and deep breathing prevent respiratory complications like pneumonia, a significant risk due to immobility post-surgery. A high-residue diet prevents constipation, positioning varies, and exercises are secondary to respiratory care.
The nurse is caring for a client with a history of burn injuries.
- A. Which intervention is most important for a client with major burn injuries?
- B. Maintain strict aseptic technique.
- C. Administer oral fluids to prevent dehydration.
- D. Apply cold compresses to burn sites.
- E. Restrict protein intake.
Correct Answer: A
Rationale: Strict aseptic technique prevents infection, a major cause of mortality in burn patients due to loss of skin barrier. IV fluids are used, cold compresses worsen tissue damage, and high-protein diets support healing.
The client who is receiving hydantoin (Dilantin) tells the nurse his urine is pink-colored. What action should the nurse take?
- A. Report this serious side effect immediately to the physician
- B. Reassure the client that this occurs often in persons taking Dilantin
- C. Ask the client if he drank cranberry juice or ate red gelatin recently
- D. Strain the client's urine for possible urinary tract stones
Correct Answer: C
Rationale: Pink urine may result from dietary factors like cranberry juice or red gelatin, which should be ruled out before assuming a Dilantin-related issue.
A client has returned from having a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
- A. An hourly urinary output of 40-50 mL
- B. Bright red urine with many clots
- C. Dark red urine with few clots
- D. Requests for pain med every 4 hours
Correct Answer: B
Rationale: Bright red urine with many clots indicates significant bleeding post-prostatectomy, requiring immediate reporting. Normal output is 40-50 mL/hour, dark red urine with few clots is expected, and pain med requests are routine.
The nurse is caring for a client receiving chemotherapy.
- A. Which symptom should the nurse report immediately for a client receiving chemotherapy?
- B. Nausea and vomiting.
- C. A temperature of 100.8°F (38.2°C).
- D. Fatigue and weakness.
- E. Alopecia.
Correct Answer: B
Rationale: A temperature of 100.8°F indicates possible infection, a life-threatening complication in chemotherapy patients due to immunosuppression. Nausea, fatigue, and alopecia are expected side effects but less urgent.