Nokea
The nurse is caring for the client with problems of anxiety and confusion in the critical phase of burn injury. Which interventions should the nurse implement? Select all that apply.
- A. Repeat orientation statements of person, place, and time.
- B. Turn and reposition the client at least every 2 hours.
- C. Place familiar objects from home near the client.
- D. Implement a schedule for regular sleep-wake cycles.
- E. Control distractions by keeping the room door closed.
- F. Encourage the client to write notes to family members.
Correct Answer: A,C,D
Rationale: Reiterating statements of orientation to the client decreases confusion. Familiar objects reduce anxiety when clients are in unfamiliar surroundings. Employing a regular schedule for sleep-wake cycles assists in decreasing confusion and anxiety. Turning and repositioning improves circulation and aeration but does not affect confusion. Closing the door of the room may increase client anxiety. In the acute phase of burns, the client is too ill to write notes to family members.
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The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance.
- B. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit.
- C. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift.
- D. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing.
Correct Answer: B
Rationale: Delaying turning immobile clients risks pressure ulcers, requiring immediate intervention. Bed elevation, restocking, and Thick-It are appropriate.
Aside from blood on the anterior end of the packing, what other sign or symptom would suggest that the client is bleeding from the operative area?
- A. Frequent swallowing
- B. Impaired appetite
- C. Slight hoarseness
- D. Diminished hearing
Correct Answer: A
Rationale: Frequent swallowing may indicate blood trickling down the throat.
The nurse is caring for the client with psoriasis taking methotrexate. Which laboratory tests are most important for the nurse to monitor? Select all that apply.
- A. Serum potassium level
- B. Liver function tests
- C. Serum glucose level
- D. Arterial blood gases
- E. White blood cells
Correct Answer: B,E
Rationale: The nurse should monitor liver function tests because methotrexate (Trexall) is metabolized by the liver, and a side effect is hepatotoxicity. The nurse should monitor WBCs because a side effect of methotrexate use is leukopenia. Methotrexate has no effect on serum potassium unless complications arise. Glucose monitoring is needed only if the client is diabetic. ABGs are not prescribed for routine monitoring.
Which of the following clients should have his clothing removed immediately?
- A. A 32-year-old man who was burned while working on high-tension wires
- B. A 14-year-old boy who suffered severe smoke inhalation during a fire at school
- C. A 78-year-old man who was burned during a fire that started when the client fell asleep while smoking
- D. A 19-year-old student who spilled chemicals on himself in the chemistry lab at school
Correct Answer: D
Rationale: Clothing must be removed immediately in chemical burns to prevent further skin exposure and damage from the corrosive substance.
The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?
- A. Superficial partial thickness.
- B. Deep partial thickness.
- C. Full thickness.
- D. First degree.
Correct Answer: B
Rationale: Blistered, mottled red skin with edema indicates deep partial-thickness burns, affecting the dermis with severe pain. Superficial partial thickness has no blisters, full thickness is painless and leathery, and first degree is superficial with erythema.