Nokea
The nurse knows that the client who underwent a stapedectomy understands the discharge instructions when the client identifies which activity to avoid for the next 6 months?
- A. Listening to music
- B. Flying in an airplane
- C. Driving an automobile
- D. Singing in the choir
Correct Answer: B
Rationale: Pressure changes during flying can disrupt healing after a stapedectomy.
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Which nursing action is most appropriate at this time?
- A. Obtaining the client's pulse and blood pressure
- B. Monitoring the client for respiratory distress
- C. Identifying the client's next of kin
- D. Determining the extent of the burn
Correct Answer: B
Rationale: Burns to the chest and neck risk airway compromise, requiring respiratory monitoring.
Before the client's arrival, which services should the nurse anticipate will facilitate this client's recovery? Select all that apply.
- A. Nutritional consult
- B. Nutritional therapy
- C. Enterostomal therapy
- D. Psychiatric therapy
- E. Physician consult
- F. Occupational therapy
Correct Answer: A,B,C,E,F
Rationale: These services address nutrition, wound care, medical oversight, and functional recovery.
The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
- A. Elevated serum sodium and potassium levels
- B. Increased hemoglobin and hematocrit levels
- C. Excess intravenous fluid volume replacement
- D. Leakage of plasma into the interstitial space
Correct Answer: D
Rationale: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.
Which comment made to the nurse strongly suggests that the client with glaucoma needs more teaching?
- A. I must wash my hands before instilling the dress.
- B. This drug decreases the formation of fluid in my eye.
- C. I'll need to take this until my eye pressure is normal.
- D. The cap on the container should be replaced after use.
Correct Answer: C
Rationale: Glaucoma requires lifelong treatment, not just until pressure normalizes.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client’s lower extremity burn. Which assessment data would require immediate attention by the nurse?
- A. The client complains of pain when the medication is administered.
- B. The client’s potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
- C. The client’s ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
- D. The client is able to perform active range-of-motion exercises.
Correct Answer: C
Rationale: ABGs showing low HCO3 (20) and pH 7.34 suggest metabolic acidosis, a serious mafenide side effect requiring immediate attention. Pain is expected, electrolytes are normal, and ROM is positive.