Nokea
The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
- A. Elevated serum sodium and potassium levels
- B. Increased hemoglobin and hematocrit levels
- C. Excess intravenous fluid volume replacement
- D. Leakage of plasma into the interstitial space
Correct Answer: D
Rationale: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.
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When the client asks about the cause of shingles, the nurse answers correctly with which cause of the disease?
- A. The reactivation of a dormant virus
- B. A vector insect such as a tick
- C. A toxin from a bacterial infection
- D. An antibody response to a drug allergen
Correct Answer: A
Rationale: Shingles results from reactivation of the varicella-zoster virus.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client’s lower extremity burn. Which assessment data would require immediate attention by the nurse?
- A. The client complains of pain when the medication is administered.
- B. The client’s potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
- C. The client’s ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
- D. The client is able to perform active range-of-motion exercises.
Correct Answer: C
Rationale: ABGs showing low HCO3 (20) and pH 7.34 suggest metabolic acidosis, a serious mafenide side effect requiring immediate attention. Pain is expected, electrolytes are normal, and ROM is positive.
The nurse is preparing the plan of care for a client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care?
- A. Apply a thin dusting with Mycostatin, an antifungal powder, over the area.
- B. Cover the area with an occlusive dressing after applying a steroid cream.
- C. Administer acyclovir, an antiviral medication, to the affected areas six (6) times a day.
- D. Teach the client the risks and hazards of implanted radiation therapy.
Correct Answer: B
Rationale: Occlusive dressings with steroids enhance absorption, treating psoriasis. Mycostatin is for fungal infections, acyclovir is for viral infections, and radiation is irrelevant.
Which measure is best for the nurse to recommend?
- A. Soak affected body parts in a warm solution that is approximately 100°F (37.8°C).
- B. Massage the affected areas to restore circulation.
- C. Apply a heating pad on the highest setting to the affected body parts.
- D. Flood the affected skin surface with hot water at a temperature of approximately 140°F (60°C).
Correct Answer: A
Rationale: Warm soaking at 100°F promotes rewarming without causing burns.
Which client would most likely be at risk for the development of a carbuncle?
- A. The young male who is just beginning to shave.
- B. The female with a fair complexion.
- C. The male who works out in the gym daily.
- D. The female diagnosed with diabetes mellitus.
Correct Answer: D
Rationale: Diabetes increases infection risk, including carbuncles, due to impaired immunity. Shaving, fair skin, and exercise are less significant.