Nokea
Three days ago the client received circumferential, partial, and full-thickness burns to 30% total body surface area of the chest and abdomen. The nurse monitors the client for restricted breathing due to Which physiological response?
- A. Development of a layer of eschar
- B. Loss of elastin and collagen in the tissues
- C. Hypoxia and ischemia of the lungs' alveoli
- D. Fluid overload in the alveoli of the lungs
Correct Answer: A
Rationale: A layer of eschar or devitalized tissue commonly forms over partial- and full-thickness burns, which, when circumferential and when combined with increased fluid retention, can restrict circulation and lung expansion. Loss of tissue containing elastin and collagen does occur in partial- and full-thickness burns but would not be a source of constriction that would prevent lung expansion. Ischemia and hypoxia may be experienced in the alveoli due to inhalation burns; however, restricted breathing (a mechanical process) is more of a risk due to circumferential eschar formation. Although fluid overload is a possibility, it is not likely to restrict breathing unless it is combined with eschar formation.
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The client with the condition illustrated is prescribed adapalene topical daily to the affected areas. Which information should the nurse exclude when planning client education?
- A. The client has acne vulgaris, an inflammatory disease involving the sebaceous glands of the skin characterized by papules or pustules or comedones.
- B. Adapalene should be applied once daily in the evening.
- C. Exposing the back to the sun after adapalene (Differin) is applied.
- D. Only a thin film of adapalene should be applied.
Correct Answer: C
Rationale: The nurse should exclude exposing the back to the sun after adapalene (Differin) is applied. This increases the risk for sunburn. Adapalene should also not be applied to sunburned areas. The client has acne vulgaris. Adapalene should be applied once daily in the evening with a thin film.
The nurse must withhold medication administration and notify the physician if which drug is ordered for a client with glaucoma?
- A. Atropine sulfate (Sal-Tropine)
- B. Morphine sulfate (Roxanol)
- C. Magnesium sulfate (Epsom salts)
- D. Ferrous sulfate (Feosol)
Correct Answer: A
Rationale: Atropine can increase intraocular pressure, worsening glaucoma.
A severely burned client is to be admitted from the emergency department. What type of room should the nurse prepare for the client?
- A. A semi-private room with a noninfectious client
- B. A room with a postoperative client
- C. An isolation room
- D. A private room with a private bath
Correct Answer: C
Rationale: An isolation room is necessary to reduce the risk of infection, a major complication in burn clients due to compromised skin barriers.
The female teacher comes to the school nurse’s office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement?
- A. Instruct the teacher to go to her HCP today.
- B. Tell the teacher to wash her hands with soap and water.
- C. Encourage the teacher to rub vitamin E oil on the lesions.
- D. Explain that the rash will go away in a few days.
Correct Answer: A
Rationale: Impetigo requires HCP evaluation for antibiotics. Handwashing is preventive, vitamin E is ineffective, and spontaneous resolution is unlikely.
The client has an entrance wound on the right hand and an exit wound on the left hand after contact with a high-power electrical line. Considering the nature and trajectory of the electrical current, which nursing action is priority?
- A. Obtain a 12-lead ECG
- B. Check pupil size and reaction
- C. Auscultate both lung fields
- D. Check arm range of motion
Correct Answer: A
Rationale: Electrical current will follow through the path of least resistance in the body, which is the bloodstream. The heart could have been damaged by the electrical current. Therefore, obtaining a 12-lead ECG is priority. Pupil checks or lung auscultation may be indicated but are not the priority. ROM is not a priority based on the ABCs of medical emergencies.