Nokea
The nurse is performing a physical assessment on a client who has a round, non-tender nodule on the left wrist. It would be appropriate for the nurse to identify this as a
- A. janeway lesion
- B. bouchard node
- C. ganglion cyst
- D. pilar cyst
Correct Answer: C
Rationale: A round, non-tender nodule on the wrist is characteristic of a ganglion cyst, a benign fluid-filled sac.
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The nurse cares for a client who sustained full-thickness thermal burns to 30% of their total body surface area (TBSA). Which of the following initial laboratory values would be expected?
- A. Potassium 5.6 mEq/L (mmol) [3.5-5 mEq/L]
- B. Hematocrit 30% (0.30 L/L) [ Male: 42-52% Female: 37-47%, 0.38-0.50 L/L]
- C. BUN 14 mg/dL (5.0004 mmol/L)[10-20 mg/dL, 2.1-8.0 mmol/L]
- D. Glucose 89 mg/dL (4.94 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
Correct Answer: A
Rationale: Hyperkalemia (elevated potassium) is expected initially due to cell destruction from burns releasing potassium into the bloodstream.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 1 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Which two (2) assessment findings is the nurse most concerned with?
- A. h
- B. Extent of injury
- C. Oral temperature
- D. Type of burns
- E. Sensation in the right arm
Correct Answer: B, E
Rationale: The extent of injury (full- and partial-thickness burns) and loss of sensation in the right arm (indicating possible nerve damage) are critical concerns requiring immediate attention.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 3 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Based on the clinical data, the nurse's immediate concern is the client's
- A. risk for infection
- B. thermoregulation
- C. airway patency
- D. fluid volume deficit
Correct Answer: D
Rationale: Fluid volume deficit is the immediate concern due to significant fluid loss from extensive burns, risking hypovolemic shock.
The nurse plans to take which priority action?
- A. Assess the client's respiratory status
- B. Prepare an infusion of lactated ringers
- C. Insert an indwelling urinary catheter
- D. Obtain an accurate weight
Correct Answer: A
Rationale: Respiratory status is the priority due to the risk of airway compromise from burns to the torso and back.
A nurse is assigned to care for a client who reportedly has no special skincare needs. However, upon assessment, the nurse observes reddened areas over bony prominences. What action should the nurse take?
- A. Document the finding and continue with routine care
- B. Apply a topical antibiotic ointment to the affected areas
- C. Conduct and document an emergency assessment
- D. Perform and document a focused assessment of skin integrity
Correct Answer: D
Rationale: Reddened areas over bony prominences suggest early pressure ulcers, requiring a focused skin integrity assessment to guide interventions.