Nokea
The nurse recognizes that rewarming a client with hypothermia must be done slowly to prevent
- A. Superficial burns
- B. ventricular fibrillation
- C. frostbite
- D. muscle spasms
Correct Answer: B
Rationale: Rapid rewarming can cause ventricular fibrillation due to sudden changes in core temperature affecting cardiac rhythm. Slow rewarming helps stabilize the cardiovascular system.
You may also like to solve these questions
Which of the following would the nurse recognize as an accurate statement regarding pressure ulcers? Select all that apply.
- A. In a stage Il pressure ulcer, part of the dermis and epidermis are lost.'
- B. In a stage I pressure ulcer, there is a loss of integrity of the epidermis only.'
- C. In a stage Ill pressure ulcer, a deep tissue injury can expose fat.'
- D. In a stage IV pressure ulcer, the base of the wound is covered by eschar.'
- E. Stage Ill involves extensive tissue damage and can lead to bone and muscle involvement.'
Correct Answer: A, C
Rationale: Stage II involves partial loss of dermis and epidermis, and Stage III can expose fat. Stage I is non-blanchable redness, Stage IV may expose bone/muscle, and eschar is not always present.
Which of the following interventions by the newly hired nurse requires follow-up? Select all that apply.
- A. Applies zinc oxide to the client's perineal skin
- B. Provides a donut pillow while the client is sitting in the chair
- C. Maintain the head of the client's bed at 90 degrees
- D. Encourages the client to consume foods rich in carbohydrates
- E. Uses a pillow to float the client's heels
Correct Answer: B, C
Rationale: Donut pillows can increase pressure on surrounding tissues, worsening ulcer risk. Maintaining the head of the bed at 90 degrees increases shearing forces, promoting ulcer development. Zinc oxide, high-protein diets (not just carbohydrates), and floating heels are appropriate interventions.
The nurse in the emergency department (ED) is caring for a 29-year-old male client.
Item 1 of 1
Nurses' Notes
2122: Client arrives via emergency medical services (EMS) for a thermal burn sustained while igniting fireworks. On assessment, the client sustained full-thickness burns to the face, anterior torso, bilateral arms, and bilateral legs. Vital signs: T 99.7° F (37.6° C), P 106, RR 24, BP 188/90, pulse oximetry reading 95% on room air.
Based on the client's injuries, the client has sustained a ………………… total body surface area burn.
- A. 50%
- B. 75%
- C. 46.50%
- D. 76.50%
Correct Answer: D
Rationale: Using the rule of nines: face (9%), anterior torso (18%), bilateral arms (18%), bilateral legs (36%) = 9 + 18 + 18 + 36 = 81% (closest to 76.5% in options).
The nurse is caring for a client who sustained 18% full-thickness burns. The nurse understands that the treatment goal during the acute emergent (resuscitation) phase is to
- A. collaborate with occupational and physical therapy
- B. provide outpatient referrals
- C. administer parenteral nutritional replacement
- D. initiate intravenous (IV) fluids
Correct Answer: D
Rationale: During the acute emergent phase, the priority is to initiate IV fluids to prevent hypovolemic shock due to fluid loss from burns.
Place the following actions in the order in which they need to be performed, starting with the highest priority action.
- A. Initiate a large-bore peripheral vascular access device
- B. Perform a respiratory assessment and inspect the client's nose and mouth
- C. Administer prescribed intravenous (IV) pain medication
- D. Administer prescribed intravenous (IV) fluids
- E. Perform wound care to the affected area(s)
Correct Answer: B, A, D, C, E
Rationale: Respiratory assessment is first to ensure airway patency, followed by IV access and fluids for resuscitation, pain medication for comfort, and wound care last.