Nokea
The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
- A. Increase the IV rate and monitor for burn shock.
- B. Monitor for signs of seizure activity.
- C. Assess for signs of fluid overload.
- D. Raise the foot of the bed and apply blankets.
Correct Answer: C
Rationale: As the blood volume increases, the cardiac output increases to increase renal perfusion. The result includes diuresis. However, a great risk for the patient includes fluid overload because of the rapid movement of fluid back into the intravascular space. Burn shock occurs from hypovolemia in the first 72 hours of a burn injury. Seizures are not associated with the burn injury. Raising the foot of the bed would not be of value in this situation.
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A patient with severe eczema is starting a coal tar derivative treatment. Which will the nurse include in the teaching plan for the patient relative to this treatment?
- A. Drink at least 1000 mL of fluid daily.
- B. Avoid exposure to sunlight for 72 hours after use.
- C. Bathe with an astringent soap.
- D. Reduce intake of high calcium foods.
Correct Answer: B
Rationale: Persons using coal tar derivatives should avoid exposure to sunlight for 72 hours after use. The product stains clothes and bathroom fixtures. There is no need to drink additional fluids, bathe with astringent soaps or reduce calcium rich foods.
Which is a major function of the skin?
- A. Excretion of wastes
- B. Protection
- C. Vitamin C synthesis
- D. Temperature regulation
- E. Prevention of dehydration
Correct Answer: A,B,D,E
Rationale: Functions of the skin include protection from the environment (pathogenic organisms, foreign substances, natural barrier against infection), temperature regulation, prevention of dehydration, excretion of waste products, and vitamin D synthesis.
Which action will the nurse take when administering a therapeutic bath to a patient who has severe pruritus from contact dermatitis?
- A. Use Burow's solution to help promote healing.
- B. Rub the skin briskly to decrease pruritus.
- C. Limit bathing to three times a week.
- D. Ensure that bath area is at least 85 degrees and dehumidified.
Correct Answer: A
Rationale: Pruritus is responsible for most of the discomfort. Wet dressings and using Burow's solution help promote the healing process. Rubbing the skin would increase pruritis. Give daily baths with an application to cleanse the skin. A cool environment with increased humidity decreases the pruritus.
The most deadly skin cancer is
- A. melanoma
Correct Answer: melanoma
Rationale: Malignant melanoma is a cancerous neoplasm that invades the epidermis, dermis, and sometimes the subcutaneous tissue.
The three major glands of the skin are sudoriferous, ceruminous, and
- A. sebaceous
Correct Answer: sebaceous
Rationale: Sudoriferous glands-sweat glands open into pores on the skin surface and excrete sweat. Ceruminous glands-secrete a waxlike substance called cerumen and are located in the external ear canal. Sebaceous glands-secrete their substance, sebum (an oily secretion), through the hair follicles distributed on the body.