Nokea
The nurse is caring for an elderly female client preoperative for facial reconstruction. Which client problem should the nurse include in the preoperative plan of care?
- A. Loss of self-esteem.
- B. Alteration in comfort.
- C. Ineffective airway clearance.
- D. Impaired communication.
Correct Answer: A
Rationale: Facial reconstruction may impact self-esteem due to appearance concerns. Comfort, airway, and communication are less relevant preoperatively.
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The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, 'What is a xenograft?' Which statement by the nurse would be the best response?
- A. The doctor will graft skin from your back to your leg.'
- B. The skin from a donor will be used to cover your burn.'
- C. The graft will come from an animal, probably a pig.'
- D. I think you should ask your doctor about the graft.'
Correct Answer: C
Rationale: A xenograft uses animal skin (e.g., porcine) for temporary burn coverage. Autografts use the patient’s skin, allografts use donor human skin, and deferring to the doctor avoids education.
Three days ago the client received circumferential, partial, and full-thickness burns to 30% total body surface area of the chest and abdomen. The nurse monitors the client for restricted breathing due to Which physiological response?
- A. Development of a layer of eschar
- B. Loss of elastin and collagen in the tissues
- C. Hypoxia and ischemia of the lungs' alveoli
- D. Fluid overload in the alveoli of the lungs
Correct Answer: A
Rationale: A layer of eschar or devitalized tissue commonly forms over partial- and full-thickness burns, which, when circumferential and when combined with increased fluid retention, can restrict circulation and lung expansion. Loss of tissue containing elastin and collagen does occur in partial- and full-thickness burns but would not be a source of constriction that would prevent lung expansion. Ischemia and hypoxia may be experienced in the alveoli due to inhalation burns; however, restricted breathing (a mechanical process) is more of a risk due to circumferential eschar formation. Although fluid overload is a possibility, it is not likely to restrict breathing unless it is combined with eschar formation.
Which nursing instruction is most appropriate to convey to the client?
- A. Use hypoallergenic or glycerin soap for bathing.
- B. Apply lotion to the affected skin every other day.
- C. Take showers rather than tub baths.
- D. Rub the skin dry after bathing.
Correct Answer: A
Rationale: Hypoallergenic soap minimizes irritation in dry skin.
The public health nurse is caring for a client diagnosed with leprosy (Hansen’s disease). Which intervention should the nurse implement?
- A. Explain the need for admission to the hospital.
- B. Administer dapsone, a sulfone, for one (1) month only.
- C. Instruct to use skin moisturizing lotion to control the symptoms.
- D. Discuss the ways leprosy is transmitted to other individuals.
Correct Answer: D
Rationale: Discussing transmission (e.g., prolonged contact) educates the client, reducing stigma and risk. Hospitalization is rarely needed, dapsone is long-term, and lotion is symptomatic.
The nurse is determining the IV fluid needs for the 50-kg client with partial-thickness burns to 40% total body surface area (TBSA). Using the Parkland formula (4 mL X weight in kg X % TBSA burn = 24-hour IV fluid volume replacement; half given in first 8 hours), how many mL of IV fluid are needed during the first 8 hours after injury? mL of IV fluid (Record your answer as a whole number.)
- A. 4000
Correct Answer: A
Rationale: Use the Parkland formula provided: 4.0 mL at 50 kg = 200 mL; 200 mL × 40% TBSA burn = 8000 mL. Half of 8000 mL, or 4000 mL, is given in the first 8 hours after the burn.