NS 520: UNIT III

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Question 1 of 1

Time Left

605270

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During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Select the correct answer(s).

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Explanation

When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient’s weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

605271

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While the patient’s full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination?

Select the correct answer(s).

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Explanation

Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

605272

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A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first?

Select the correct answer(s).

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Explanation

The decrease in pulse and numbness in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient’s circulation.

605273

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A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

Select the correct answer(s).

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Explanation

All patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.

605274

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Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit?

Select the correct answer(s).

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Explanation

An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

605275

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The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?

Select the correct answer(s).

(0/0)

Explanation

During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan.

605276

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Which menu choice indicates that the patient understands the nurse’s teaching about recommended dietary choices for iron-deficiency anemia?

Select the correct answer(s).

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Explanation

Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

605277

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A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of

Select the correct answer(s).

(0/0)

Explanation

Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

605278

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Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

Select the correct answer(s).

(0/0)

Explanation

Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

605279

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A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse’s first action should be to

Select the correct answer(s).

(0/0)

Explanation

The patient’s symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

605280

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A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

Select the correct answer(s).

(0/0)

Explanation

The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

605281

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The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Select the correct answer(s).

(0/0)

Explanation

UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.

605282

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Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?

Select the correct answer(s).

(0/0)

Explanation

Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.

605283

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A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?

Select the correct answer(s).

(0/0)

Explanation

The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient’s home environment.

605284

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An appropriate nursing intervention for a patient with non-Hodgkin’s lymphoma whose platelet count drops to 18,000 during chemotherapy is to

Select the correct answer(s).

(0/0)

Explanation

Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

NS 520: UNIT III

Question 1 of 1

Time Left

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Select the correct answer(s).

(0/0)

Explanation

While the patient’s full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination?

Select the correct answer(s).

(0/0)

Explanation

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first?

Select the correct answer(s).

(0/0)

Explanation

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

Select the correct answer(s).

(0/0)

Explanation

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit?

Select the correct answer(s).

(0/0)

Explanation

The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?

Select the correct answer(s).

(0/0)

Explanation

Which menu choice indicates that the patient understands the nurse’s teaching about recommended dietary choices for iron-deficiency anemia?

Select the correct answer(s).

(0/0)

Explanation

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of

Select the correct answer(s).

(0/0)

Explanation

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

Select the correct answer(s).

(0/0)

Explanation

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse’s first action should be to

Select the correct answer(s).

(0/0)

Explanation

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

Select the correct answer(s).

(0/0)

Explanation

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Select the correct answer(s).

(0/0)

Explanation

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?

Select the correct answer(s).

(0/0)

Explanation

A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?

Select the correct answer(s).

(0/0)

Explanation

An appropriate nursing intervention for a patient with non-Hodgkin’s lymphoma whose platelet count drops to 18,000 during chemotherapy is to

Select the correct answer(s).

(0/0)

Explanation

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