Nokea
The nurse is caring for the client with a burn injury. Which findings should prompt the nurse to notify the HCP because the client may be developing sepsis?
- A. Paco2 35 mm Hg and blood glucose level 250
- B. Bleeding from IV site and blood glucose level 55
- C. Temperature 103.2°F (39.6°C) and heart rate 120 bpm
- D. Respiratory rate 34 breaths/min and WBC 10,000/mm3
Correct Answer: C
Rationale: T 103.2°F (39.6°C) and HR 120 bpm may indicate that the client has sepsis. A Paco2 35 mm Hg is WNL. Hyperglycemia does occur in sepsis, but this alone is not sufficient. Abnormal clotting may occur with sepsis, but hypoglycemia does not. An RR of 34 breaths/min may indicate sepsis, but the WBC is WNL.
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During the initial assessment, the nurse can assist the physician in determining the etiology of the client's problem by assessing if there is a history of which condition?
- A. Recent nasal injury
- B. Respiratory allergies
- C. Previous nasal surgery
- D. A past tonsillectomy
Correct Answer: B
Rationale: Respiratory allergies are a common cause of nasal polyps.
The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse?
- A. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch.
- B. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally.
- C. The skin covering the coccyx is intact but the client complains of pain in the area.
- D. The coccyx wound extends to the subcutaneous layer and there is drainage.
Correct Answer: D
Rationale: Extension to the subcutaneous layer with drainage indicates progression to stage III or IV, worsening the ulcer. Smaller size, blisters, or pain are less severe.
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client’s mental health?
- A. Encourage the client to stay at home as much as possible.
- B. Discuss the importance of not relying on the family for needs.
- C. Tell the client to remember that changes in lifestyle take time.
- D. Instruct the client to discuss feelings only with the therapist.
Correct Answer: C
Rationale: Acknowledging lifestyle changes promotes mental health by fostering realistic expectations. Isolation, independence from family, or limiting discussions hinder recovery.
The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement?
- A. This surgery will create a skin flap to cover my wounds.'
- B. This surgery will get all the old black tissue out of the wound so it can heal.'
- C. The surgery is important to allow oxygen to get to the tissue for healing to occur.'
- D. Stool will come out an opening in my abdomen so it won’t get in the sore.'
Correct Answer: D
Rationale: Fecal diversion (colostomy) prevents stool contamination of coccyx ulcers, aiding healing. Skin flaps, debridement, and oxygen delivery are unrelated to this surgery.
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority?
- A. High risk for infection.
- B. Ineffective coping.
- C. Impaired physical mobility.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Extensive burns increase infection risk due to loss of skin barrier; this is the priority. Coping, mobility, and knowledge are secondary in acute burn care.