Nokea
When a foreign body becomes embedded in a client's eye, which nursing action should be taken first before referring the client for emergency treatment?
- A. Remove the object with forceps.
- B. Ask the person to blink rapidly.
- C. Instill antibiotic ointment.
- D. Loosely patch both eyes.
Correct Answer: D
Rationale: Patching both eyes prevents eye movement, reducing further damage until emergency treatment is received.
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Which other assessment finding is most indicative of an infection in the external ear?
- A. Foul-smelling drainage
- B. Scarred tympanic membrane
- C. Diminished hearing
- D. Enlarged lymph nodes
Correct Answer: A
Rationale: Foul-smelling drainage is a hallmark of external ear infections.
The client is scheduled for application of a cadaver homograph to a burn on the forearm. Which comment by the client demonstrates an accurate understanding of this procedure?
- A. The graft donor site from my right upper thigh shouldn't take too long to heal.
- B. I know this graft will only be a temporary measure to protect and help heal my arm.
- C. I am glad that there is no risk of me getting a blood-borne disease with this type of graft.
- D. If this graft doesn't permanently take, then I'll need to select another graft donor site.
Correct Answer: B
Rationale: A cadaver skin graft is a type of temporary graft, also called a biological dressing, and it is used to protect the damaged skin and promote healing and epithelialization. A cadaver skin graft does not use the client's own skin, so there is no donor site. There is a risk of transmitting blood-borne infections with cadaver grafts. The graft is not permanent, so no further donor site selection is needed.
The nurse is caring for the client with a burn injury. Which findings should prompt the nurse to notify the HCP because the client may be developing sepsis?
- A. Paco2 35 mm Hg and blood glucose level 250
- B. Bleeding from IV site and blood glucose level 55
- C. Temperature 103.2°F (39.6°C) and heart rate 120 bpm
- D. Respiratory rate 34 breaths/min and WBC 10,000/mm3
Correct Answer: C
Rationale: T 103.2°F (39.6°C) and HR 120 bpm may indicate that the client has sepsis. A Paco2 35 mm Hg is WNL. Hyperglycemia does occur in sepsis, but this alone is not sufficient. Abnormal clotting may occur with sepsis, but hypoglycemia does not. An RR of 34 breaths/min may indicate sepsis, but the WBC is WNL.
The nurse is caring for clients with second- and third-degree burns. Which medication should the nurse plan to apply topically to treat bacterial and yeast infections?
- A. Bismuth subsalicylate
- B. Gold sodium thiomalate
- C. Silver sulfadiazine
- D. Arsenic trioxide
Correct Answer: C
Rationale: Silver sulfadiazine (Silvadene) is a topical anti-infective agent for prevention and treatment of wound infection in second- and third-degree burn clients. Bismuth subsalicylate (Kaopectate) is an antidiarrheal medication. Gold sodium thiomalate (Aurolate) is used to treat rheumatoid arthritis resistant to conventional therapy. Arsenic trioxide (Trisenox) is an antineoplastic.
After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate?
- A. Wrap ice in a washcloth and put it on the burn area.
- B. Come to the ED so a doctor can assess your fingers.
- C. Run cool water over the burned area on your fingers.
- D. Apply an antibiotic skin ointment to prevent infection.
Correct Answer: C
Rationale: Ice causes vasoconstriction and can worsen the tissue damage. The nurse should collect additional information before advising that the client be seen in the ED. A first-degree burn ordinarily does not require medical care. Cool water will minimize skin redness, pain, and swelling and limit tissue damage. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an oily base, it can prevent healing.