SKIN
Which intervention is most important for a person who is in a wheelchair for long periods?
a. Reposition self every 2 h.
b. Lift weight on the arms of the chair every 15 minutes. c. Massage bony prominences of the buttocks and hips. d. Use a donut device to keep weight off of the buttocks.
ANS: b
Lifting or off-loading weight every 15 minutes while in a wheelchair will reduce the threat of pressure ulcer. Tissue anoxia can result in less than 2 h. Movement to shift weight every 15 minutes is most effective.Massage can damage delicate tissues in the at-risk patient. The donut device reduces circulation to the area compressed and is contraindicated.
ACETAMINOPHEN ANTIDOTE
ACETYLCYSTEINE (mucomyst)
Which symptom is consistent with an inhalation burn?
a. Full-thickness burns to chest
b. Hypotension
c. Agitation
d. Persistent coughing
ANS: d
Persistent coughing, particularly if black mucus is coughed up, is an indicator of an inhalation burn.
Right knee replacement patient has been refusing therapy, meds, and CPM machine. Today you go in to see her and she states she would like a pain pill. She has been refusing pain meds along with everything else for a few days now. You think, huh? What changed?
You go to assess her leg and note that it is markedly edematous (4+) and weeping at suture sites. Patient complains of pain no matter where you touch. She says it hurts everywhere especially behind her knee up to her thigh.
What is happening with this patient?
DVT
2 PART QUESTION
A newly admitted 86-year-old patient has scratch marks in the groin and axilla and on her limbs. There are small, punctate red lesions that the patient says itch "like crazy." Which nursing action is most appropriate?
a. Employ skin tear precautions.
b. Employ Standard Precautions.
c. Employ use of emollient.
d. Employs focused assessment for cause
AND WHAT IS MOST LIKELY OCCURING WITH THIS PATIENT
ANS: b
The patient is most likely suffering from scabies. The nurse should
employ Standard Precautions in order to avoid the spread of infection.
Heparin Antidote
Protamine Sulfate
The nurse is providing fluid resuscitation for a burn victim according to the Parkland formula. The nurse determines that the patient requires 8000 mL in a 24-h time period. The burn occurred at noon, and the present time is 1400. How many milliliters of fluid should infuse by 2000?
a. 2000 mL b. 3000 mL c. 4000 mL d. 7000 mL
ANS: c
According to the Parkland formula, one half of the fluid resuscitation load should be infused within 8 h from the time of the burn. The burn occurred at noon, so by 8:00 P.M., 4000 mL should have been infused of the 8000 mL calculated.
You are caring for a patient with a T6 fracture who get I&O caths Q6 hours. Patient calls and is C/O severe H/A and is sweating and red from neck up. He has goose bumps and is pale everywhere else.
BP is 186/110. Quick search reveals Bladder is non-palpable, last BM soft-formed this morning.
Autonomic Dysreflexia
Elevate HOB to 45 degrees, give prn BP med, and then keep looking for cause!
Everything looks okay until pull covers back over feet.
The nurse is caring for a patient and during the assessment, observes a full-thickness 2 cm ́ 1 cm skin tear on the right buttock. How should the nurse stage this pressure ulcer?
a. Category I b. Category II c. Category III d. Category IV
ANS: c
Category III skin tears have complete tissue loss in which the epidermal
flap is missing. Category I skin tears do not have tissue loss. Category II
skin tears reflect a partial tissue loss. There is no Category IV.
Lasix puts you at risk for what electrolyte abnormality?
hypokalemia
The nurse is caring for a burn patient. Which action best prevents contractures?
a. Assist the patient with ambulation as soon as fluid shifts stabilize.
b. Medicate the patient approximately 30 minutes prior to dressing changes.
c. Ensure adequate hydration.
d. Ensure adequate nutritional intake
ANS: a
While each of these interventions is important for management of the patient with burns, only ambulation works to prevent contractures. Other interventions address pain management, adequate hydration, and adequate nutritional intake.
Your patient has just reported numbness and partial facial paralysis on the right side only. The patient is unable to raise her right eyebrow, close her right eyelid, frown, smile, or puff out her cheeks on the right side. She is alert and oriented X3 and can raise both arms symmetrically.
Bell’s Palsy.
Encourage Facial Exercises, Consult PT, facial sling, protect eyes from dryness and prevent injury, promote frequent oral care. Reinforce patient to chew on unaffected side.
2 PART QUESTION
While bathing a patient, the nurse assesses a red, unblanchable area on the coccyx. Which type of dressing should the nurse apply?
a. Transparent film
b. Hydrocolloid
c. Fluffy absorbent
d. Wet-to-dry
AND WHAT TYPE OF PRESSURE ULCER IS IT ?
ANSWER : A
A transparent film for a stage I pressure ulcer will protect it from shearing injury and will retain moisture. A hydrocolloid dressing would be appropriate for a larger, more advanced pressure ulcer. There is no discharge in a stage I pressure ulcer, making absorbent and wet-to-dry dressing options inappropriate.
Digoxin s.s of toxicity
visual changes, n/v
Which interventions are appropriate for a burn patient newly admitted to the emergency department? (Select all that apply.)
a. Cover burns with sterile saline–saturated towels.
b. Carefully remove clothing adhered to burned areas. c. Carefully avoid disturbing blisters.
d. Remove jewelry from injured limbs.
e. Determine the causative agent of the burn.
ANS: c,d,e
The nurse should carefully avoid disturbing blisters, remove jewelry from injured limbs, and determine the causative agent of the burn. Clothing that is stuck to burn areas is not removed until the patient is admitted to the hospital. The nurse should apply a sterile dry (not wet)dressing.
Your patient has just reported severe facial pain on her left side. She states it happened this morning while she was doing her AM care: brushing her teeth and washing her face. The assessment demonstrates pain along a nerve.
Trigeminal Neuralgia
Avoid hot or cold foods and fluids, provide small frequent feedings of liquids and soft foods, reinforce instructions to patient to chew food on unaffected side. ADM Meds