Nokea
When the nurse applies mafenide acetate cream to the burn wound, the nurse should recognize which of the following as its chief disadvantage?
- A. Skin discoloration
- B. Pain on application
- C. Unpleasant odor
- D. Contact dermatitis
Correct Answer: B
Rationale: Mafenide acetate causes significant pain upon application.
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The nurse is caring for the client with a large, open sternal wound resulting from a burn injury. The client is receiving enteral feeding, Oxepa (an anti-inflammatory, pulmonary 1.5 Cal/mL formula), at 25 mL/hour. Which laboratory value finding best indicates that the client is receiving inadequate nutrition?
- A. Phosphorus
- B. Platelets
- C. Prealbumin
- D. Potassium
Correct Answer: C
Rationale: Prealbumin is used to evaluate nutritional status. A low level of prealbumin indicates inadequate nutrition. Prealbumin has a half-life of 2 days and reflects changes in serum protein stores more rapidly than other indices. The phosphorus level decreases in malnutrition as well as other conditions, but this is not the best indicator of inadequate nutrition. Platelets are essential to blood clotting and may or may not be altered with inadequate nutrition. Potassium is the major cation within the cell and may be low due to renal failure or GI disorders.
Because the immobile client slides down in bed, the nurse is correct to assess for which type of skin injury?
- A. One that results from continuous pressure
- B. One that results from a shearing force
- C. One that results from friction
- D. One that results from agitation in bed
Correct Answer: B
Rationale: Sliding causes shearing forces, damaging skin and underlying tissue.
The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first?
- A. The client scheduled for a skin biopsy who is crying.
- B. The client who had surgery three (3) hours ago and is sleeping.
- C. The client who needs to void prior to discharge.
- D. The client who has received discharge instructions and is ready to go home.
Correct Answer: A
Rationale: Crying suggests emotional distress or pain, requiring immediate assessment. Sleeping, voiding, and discharge-ready clients are stable.
Which laboratory test should the nurse monitor to identify an allergic reaction for the client diagnosed with contact dermatitis?
- A. IgA.
- B. IgD.
- C. IgE.
- D. IgG.
Correct Answer: C
Rationale: IgE mediates allergic reactions, elevated in contact dermatitis. IgA, IgD, and IgG are less relevant.
The nurse is planning the care for clients recovering from second- or third-degree burns. Which psychosocial nursing problem should be priority?
- A. Altered sensory perception
- B. Altered skin integrity
- C. Disturbed body image
- D. Disturbed personal identity
Correct Answer: C
Rationale: Disturbed body image occurs during the recovering stages of the burn condition and should be priority. Altered sensory perception and altered skin integrity are physiological problems. Disturbed personal identity is less likely to occur than disturbed body image.