Medical Surgical Nursing Questions

MEDICAL SURGICAL NURSING RESPIRATORY SYSTEM: 1. List 4 common symptoms of pneumonia the nurse might note on a physical exam. - Tachypnea, fever with chills, productive cough, bronchial breath sounds. 2. State 4 nursing interventions for assisting the client to cough productively. - Deep breathing, fluid intake increased to 3 liters/day, use humidity to loosen secretions, suction airway to stimulate coughing. 3. What symptoms of pneumonia might the nurse expect to see in an older client? - Confusion, lethargy, anorexia, rapid respiratory rate. 4. What should the O2 flow rate be for the client with COPD? - 1-2 liters per nasal cannula, too much O2 may eliminate the COPD client’s stimulus to breathe, a COPD client has hypoxic drive to breathe. 5. How does the nurse prevent hypoxia during suctioning? - Deliver 100% oxygen (hyperinflating) before and after each endotracheal suctioning. 6. During mechanical ventilation, what are three major nursing intervention? - Monitor client’s respiratory status and secure connections, establish a communication mechanism with the client, keep airway clear by coughing/suctioning. 7. When examining a client with emphysema, what physical findings is the nurse likely to see? - Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in lung fields. 8. What is the most common risk factor associated with lung cancer? - Smoking 9. Describe the pre-op nursing care for a client undergoing a laryngectomy. - Involve family/client in manipulation of tracheostomy equipment before surgery, plan acceptable communication method, refer to speech pathologist, discuss rehabilitation program. 10. List 5 nursing interventions after chest tube insertion. - Maintain a dry occlusive dressing to chest tube site at all times. Check all connections every 4 hours. Make sure bottle III or end of chamber is bubbling. Measure chest tube drainage by marking level on outside of drainage unit. Encourage use of incentive spirometry every 2 hours. 11. What immediate action should the nurse take when a chest tube becomes disconnected from a bottle or a suction apparatus? What should the nurse do if a chest tube is accidentally removed from the client? - Place end in container of sterile water. Apply an occlusive dressing and notify physician STAT. 12. What instructions should be given to a client following radiation therapy? - Do NOT wash off lines; wear soft cotton garments, avoid use of powders/creams on radiation site. 13. What precautions are required for clients with TB when placed on respiratory isolation? - Mask for anyone entering room; private room; client must wear mask if leaving room. 14. List 4 components of teaching for the client with tuberculosis. - Cough into tissues and dispose immediately into special bags. Long-term need for daily medication. Good handwashing technique. Report symptoms of deterioration, i.e., blood in secretions. RENAL SYSTEM: 1. Differentiate between acute renal failure and chronic renal failure. - Acute renal failure: often reversible, abrupt deterioration of kidney function. Chronic renal failure: irreversible, slow deterioration of kidney function characterized by increasing BUN and creatinine. Eventually dialysis is required. 2. During the oliguric phase of renal failure, protein should be severely restricted. What is the rationale for this restriction? - Toxic metabolites that accumulate in the blood (urea, creatinine) are derived mainly from protein catabolism. 3. Identify 2 nursing interventions for the client on hemodialysis. - Do NOT take BP or perform venipunctures on the arm with the A-V shunt, fistula, or graft. Assess access site for thrill or bruit. 4. What is the highest priority nursing diagnosis for clients in any type of renal failure? - Alteration in fluid and electrolyte balance. 5. A client in renal failure asks why he is being given antacids. How should the nurse reply? - Calcium and aluminum antacids bind phosphates and help to keep phosphates from being absorbed into blood stream thereby preventing rising phosphate levels, and must be taken with meals. 6. List 4 essential elements of a teaching plan for clients with frequent urinary tract infections. - Fluid intake 3 liters/day; good handwashing; void every 2-3 hours during waking hours; take all prescribed medications; wear cotton undergarments. 7. What are the most important nursing interventions for clients with possible renal calculi? - Strain all urine is the MOST IMPORTANT intervention. Other interventions include accurate intake and output documentation and administer analgesics as needed. 8. What discharge instructions should be given to a client who has had urinary calculi? - Maintain high fluid intake 3-4 liters per day. Follow-up care (stones tend to recur). Follow prescribed diet based in calculi content. Avoid supine position. 9. Following transurethral resection of the prostate gland (TURP), hematuria should subside by what post-op day? - Fourth day 10. After the urinary catheter is removed in the TURP client, what are 3 priority nursing actions? - Continued strict I&O; continued observations for hematuria; inform client burning and frequency may last for a week. 11. After kidney surgery, what are the primary assessments the nurse should make? - Respiratory status (breathing is guarded because of pain); circulatory status (the kidney is very vascular and excess bleeding can occur); pain assessment; urinary assessment most importantly, assessment of urinary output. CARDIOVASCULAR SYSTEM: 1. How do clients experiencing angina describe that pain? - Described as squeezing, heavy, burning, radiates to left arm or shoulder, transient or prolonged. 2. Develop a teaching plan for the client taking nitroglycerin. - Take at first sign of anginal pain. Take no more than 3, five minutes apart. Call for emergency attention if no relief in 10 minutes. 3. List the parameters of blood pressure for diagnosing hypertension. - >140/90 4. Differentiate between essential and secondary hypertension. - Essential has no known cause while secondary hypertension develops in response to an identifiable mechanism. 5. Develop a teaching plan for the client taking antihypertensive medications. - Explain how and when to take med, reason for med, necessary of compliance, need for follow-up visits while on med, need for certain lab tests, vital sign parameters while initiating therapy. 6. Describe intermittent claudication. - Pain related to peripheral vascular disease occurring with exercise and disappearing with rest. 7. Describe the nurse’s discharge instructions to a client with venous peripheral vascular disease. - Keep extremities elevated when sitting, rest at first sign of pain, keep extremities warm (but do NOT use heating pad), change position often, avoid crossing legs, wear unrestrictive clothing. 8. What is often the underlying cause of abdominal aortic aneurysm? - Atherosclerosis. 9. What lab values should be monitored daily for the client with thrombophlebitis who is undergoing anticoagulant therapy? - PTT, PT, Hgb, and Hct, platelets. 10. When do PVCs (premature ventricular contractions) present a grave danger? - When they begin to occur more often than once in 10 beats, occur in 2s or 3s, land near the T wave, or take on multiple configurations. 11. Differentiate between the symptoms of left-sided cardiac failure and right-sided cardiac failure. - Left-sided failure results in pulmonary congestion due to back-up of circulation in the left ventricle. Right-sided failure results in peripheral congestion due to back-up of circulation in the right ventricle. 12. List 3 symptoms of digitalis toxicity. - Dysrhythmias, headache, nausea and vomiting 13. What condition increases the likelihood of digitalis toxicity occurring? - When the client is hypokalemic (which is more common when diuretics and digitalis preparations are given together). 14. What life style changes can the client who is at risk for hypertension initiate to reduce the likelihood of becoming hypertensive? - Cease cigarette smoking if applicable, control weight, exercise regularly, and maintain a low-fat/low-cholesterol diet. 15. What immediate actions should the nurse implement when a client is having a myocardial infarction? - Place the client on immediate strict bedrest to lower oxygen demands of heart, administer oxygen by nasal cannula at 2-5 L/min., take measures to alleviate pain and anxiety (administer prn pain medications and anti-anxiety medications). 16. What symptoms should the nurse expect to find in the client with hypokalemia? - Dry mouth and thirst, drowsiness and lethargy, muscle weakness and aches, and tachycardia. 17. Bradycardia is defined as a heart rate below ___ BPM. Tachycardia is defined as a heart rate above ___ BPM. - bradycardia 60 bpm; tachycardia 100 bpm 18. What precautions should clients with valve disease take prior to invasive procedures or dental work? - Take prophylactic antibiotics. GASTROINTESTINAL SYSTEM: 1. List 4 nursing interventions for the client with a hiatal hernia. - Sit up while eating and one hour after eating. Eat small, frequent meals. Eliminate foods that are problematic. 2. List 3 categories of medications used in the treatment of peptic ulcer disease. - Antacids, H2 receptor-blockers, mucosal healing agents, proton pump inhibitors. 3. List the symptoms of upper and lower gastrointestinal bleeding. - Upper GI: melena, hematemesis, tarry stools. Lower GI: bloddy stools, tarry stools. Similar: tarry stools. 4. What bowel sound disruptions occur with an intestinal obstruction? - Early mechanical obstruction: high-pitched sounds; late mechanical obstruction: diminished or absent bowel sounds. 5. List 4 nursing interventions for post-op care of the client with a colostomy. - Irrigate daily at same time; use warm water for irrigations; wash around stoma with mild soap/water after each colostomy bag change; pouch opening should extend at least 1/8 inch around the stoma. 6. List the common clinical manifestations of jaundice. - Sclera-icteric (yellow sclera), dark urine, chalky or clay-colored stools 7. What are the common food intolerances for clients with cholelithiasis? - Fried/spicy or fatty foods. 8. List 5 symptoms indicative of colon cancer. - Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain with nausea, weight loss. 9. In a client with cirrhosis, it is imperative to prevent further bleeding and observe for bleeding tendencies. List 6 relevant nursing interventions. - Avoid injectons, use small bore needles for IV insertion, maintain pressure for 5 minutes on all venipuncture sites, use electric razor, use soft-bristle toothbrush for mouth care, check stools and emesis for occult blood. 10. What is the main side effect of lactulose, which is used to reduce ammonia levels in clients with cirrhosis? - Diarrhea. 11. List 4 groups who have a high risk of contracting hepatitis. - Homosexual males, IV drug users, recent ear piercing or tattooing, and health care workers. 12. How should the nurse administer pancreatic enzymes? - Give with meals or snacks. Powder forms should be mixed with fruit juices. ENDOCRINE SYSTEM: 1. What diagnostic test is used to determine thyroid activity? - T3 and T4 2. What condition results from all treatments for hyperthyroidism? - Hypothyroidism, requiring thyroid replacement 3. State 3 symptoms of hyperthyroidism and 3 symptoms of hypothyroidism. - Hyperthyroidism: weight loss, heat intolerance, diarrhea. Hypothyroidism: fatigue, cold intolerance, weight gain. 4. List 5 important teaching aspects for clients who are beginning corticosteroid therapy. - Continue medication until weaning plan is begun by physician, monitor serum potassium, glucose, and sodium frequently; weigh daily, and report gain of >5lbs./wk; monitor BP and pulse closely; teach symptoms of Cushing’s syndrome 5. Describe the physical appearance of clients who are Cushinoid. - Moon face, obesity in trunk, buffalo hump in back, muscle atrophy, and thin skin. 6. Which type of diabetic always requires insulin replacement? - Type I, Insulin-dependent diabetes mellitus (IDDM) 7. What type of diabetic sometimes requires no medication? - Type II, Non-insulin dependent diabetes mellitus (NIDDM) 8. List 5 symptoms of hyperglycemia. - Polydipsia, polyuria, polyphagia, weakness, weight loss 9. List 5 symptoms of hypoglycemia. - Hunger, lethargy, confusion, tremors or shakes, sweating 10. Name the necessary elements to include in teaching the new diabetic. - Teach the underlying pathophysiology of the disease, its management/treatment regime, meal planning, exercise program, insulin administration, sick-day management, symptoms of hyperglycemia (not enough insulin) 11. In less than ten steps, describe the method for drawing up a mixed dose of insulin (regular with NPH). - Identify the prescribed dose/type of insulin per physician order; store unopened insulin in refrigerator. If opened, may be kept at room temperature for up to 3 months. Draw up regular insulin FIRST. Rotate injection sites. May reuse syringe by recapping and storing in refrigerator. 12. Identify the peak action time of the following types of insulin: rapid-acting regular insulin, intermediate-acting, long-acting. - Rapid-acting regular insulin: 2-4 hrs. Immediate-acting: 6-12 hrs. Long-acting: 1420 hrs. 13. When preparing the diabetic for discharge, the nurse teaches the client the relationship between stress, exercise, bedtime snacking, and glucose balance. State the relationship between each of these. - Stress and stress hormones usually increase glucose production and increase insulin need; exercise can increase the chance for an insulin reaction, therefore, the client should always have a sugar snack available when exercising (to treat hypoglycemia); bedtime snacking can prevent insulin reactions while waiting for long-acting insulin to peak. 14. When making rounds at night, the nurse notes that an insulin-dependent client is complaining of a headache, slight nausea, and minimal trembling. The client’s hand is cool and moist. What is the client most likely experiencing? - Hypoglycemia/insulin reaction. 15. Identify 5 foot-care interventions that should be taught to the diabetic client. - Check feet daily & report any breaks, sores, or blisters to health care provider, wear well-fitting shoes; never go barefoot or wear sandals, never personally remove corns or calluses, cut or file nails straight across; wash daily with mild soap & warm water. MUSCULOSKELETAL SYSTEM: 1. Differentiate between rheumatoid arthritis and degenerative joint disease in terms of joint involvement. - Rheumatoid arthritis occurs bilaterally. Degenerative joint disease occurs asymmetrically. 2. Identify the categories of drugs commonly used to treat arthritis. - NSAIDs (nonsteroidal anti-inflammatory drugs) of which salicylates are the cornerstones (used when arthritic symptoms are severe). 3. Identify pain relief interventions for clients with arthritis. - Warm, moist heat (compresses, baths, showers), diversionary activities (imaging, distraction, self-hypnosis, biofeedback), and medications. 4. What measures should the nurse encourage female clients to take to prevent osteoporosis? - Estrogen replacement after menopause, high calcium and vitamin D intake beginning in early adulthood, calcium supplements after menopause, and weight-bearing exercise. 5. What are the common side effects of salicylates? - GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation. 6. What is the priority nursing intervention used with clients taking NSAIDs? - Administer or teach client to take drugs with food or milk. 7. List 3 of the most common joints that are replaced. - Hip, knee, finger. 8. Describe post-op stump care (after amputation) for the 1st 48 hours. - Elevate stump first 24 hours. Do not elevate stump after 48 hours. Keep stump in extended position and turn prone three times a day to prevent flexion contracture. 9. Describe nursing care for the client who is experiencing phantom pain after amputation. - Be aware that phantom pain is real and will eventually disappear. Administer pain medication; phantom pain responds to medication. 10. A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is short of breath, and is restless. What does the client most likely have? - Fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness, fever and petechiae. 11. What are the immediate nursing actions if fat embolization is suspected in a fracture/orthopedic client? - Notify physician STAT, draw blood gas results, assist with endotracheal intubation and treatment of respiratory failure. 12. List 3 problems associated with immobility. - Venous thrombosis, urinary calculi, skin integrity problems. 13. List 3 nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems. - Passive range of motion exercises, elastic stockings, and elevation of foot of bed 25 degrees to increase venous return. NEUROSENSORY/NEUROLOGICAL SYSTEMS: 1. What are the classifications of the commonly prescribed eye drops for glaucoma? - Parasympathominetics for pupillary constriction. Beta-adrenergic receptor-blocking agents to inhibit formation of aqueous humor. Carbonic anhydrase inhibitors to reduce aqueous humor production, and prostaglandin agonists to increase aqueous humor outflow. 2. Identify 2 types of hearing loss. - Conductive (transmission of sound to inner ear is blocked) and sensorineural (damage to 8th cranial nerve) 3. Write 4 nursing interventions for the care of the blind person and 4 nursing interventions for the care of the deaf person. - Care of the blind: announce presence clearly, call by name, orient carefully to surroundings, guide by walking in front of client with his/her hand in your elbow. Care of deaf: reduce distraction before beginning conversation, look and listen to client, give client full attention if they are a lip reader, face client directly. 4. In your own words describe the Glasgow Coma Scale. - An objective assessment of the level of consciousness based on a score of 3 to 15, with scores of 7 or less indicative of coma. 5. List 4 nursing diagnoses for the comatose client in order of priority. - Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, and decreased cardiac output. 6. State 4 independent nursing interventions to maintain adequate respirations, airway, and oxygenation in the unconscious client. - Position for maximum ventilation (prone or semi-prone and slightly to one side), insert airway if tongue obstructing; suction airway efficiently, monitor arterial pO2 and pCO2 and hyperventilate with 100% oxygen before suctioning. 7. Who is at risk for cerebral vascular accidents? - Persons with history of hypertension, previous TIAs, cardiac disease (atrial flutter/fibrillation), diabetes, oral contraceptive use, and the elderly. 8. Complications of immobility include the potential for thrombus development. State 3 nursing interventions to prevent thrombi. - Frequent range of motion exercises, frequent (q2h) position changes, and avoidance of positions which decrease venous return. 9. List 4 rationales for the appearance of restlessness in the unconscious client. - Anoxia, distended bladder, covert bleeding, or a return to consciousness 10. What nursing interventions prevent corneal drying in a comatose client? - Irrigation of eyes PRN with sterile prescribed solution, application of opthalmic ointment q8h, close assessment for corneal ulceration/drying. 11. When a comatose client on IV hyperalimentation begin to receive tube feedings instead? - When peristalsis resumes as evidenced by active bowel sounds, passage of flatus or bowel movement. 12. What is the most important principle in a bowel management program for a neurologic client? - Establishment of REGULARITY 13. Define cerebral vascular accident. - A disruption of blood supply to a part of the brain, which results in sudden loss of brain function. 14. A client with a diagnosis of CVA presents with symptoms of aphasia, right hemiparesis, but no memory or hearing deficit. In what hemisphere has the client suffered a lesion? - Left 15. What are the symptoms of spinal shock? - Hypotension, bladder and bowel distention, total paralysis, lack of sensation below lesion. 16. What are the symptoms of autonomic dysreflexia? - Hypertension, bladder and bowel distention, exaggerated autonomic responses, headache, sweating, goose bumps, and bradycardia 17. What is the most important indicator of increased ICP? - A change in the level of responsiveness 18. What vital sign changes are indicative of increased ICP? - Increased BP, widening pulse pressure, increased or decreased pulse, respiratory irregularities and temperature increase. 19. A neighbor calls the neighborhood nurse stating that he was knocked hard to the floor by his very hyperactive dog. He is wondering what symptoms would indicate the need to visit an emergency room. What should the nurse tell him to do? - Call his physician now and inform him/her of the fall. Symptoms needing medical attention would include vertigo, confusion or any subtle behavioral change, headache, vomiting, ataxia (imbalance), or seizure. 20. What activities and situations should be avoided that increase ICP? - Change in bed position, extreme hip flexion, endotracheal suctioning, compression of jugular veins, coughing, vomiting, or straining of any kind. 21. How do Hyperosmotic agents (osmotic diuretics) used to treat intracranial pressure act? - Dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent reabsorption, and by drawing fluid from the extravascular spaces into the plasma. 22. Why should narcotics be avoided in clients with neurologic impairment? - Narcotics mask the level of responsiveness as well as pupillary response. 23. Headache and vomiting are symptoms of many disorders. What characteristics of these symptoms would alert the nurse to refer a client to a neurologist? - Headache which is more severe upon awakening and vomiting not associated with nausea are symptoms of a brain tumor. 24. How should the head of the bed be positioned for post-craniotomy clients with infratentorial lesions? - Infratentorial – FLAT; Supratentorial – elevated 25. Is multiple sclerosis thought to occur because of an autoimmune process? - YES 26. Is paralysis always a consequence of spinal cord injury? - NO 27. What types of drugs are used in the treatment of myasthenia gravis? - Anticholinesterase drugs, which inhibit the action of cholinesterase at the nerve endings to promote the accumulation of acetylcholine at receptor sires, which should improve neuronal transmission to muscles. HEMATOLOGY/ONCOLOGY: 1. List 3 potential causes of anemia. - Diet lacking in iron, folate and/or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic agents such as lead or insecticides. 2. Write 2 nursing diagnoses for the client suffering from anemia. - Activity intolerance and altered tissue perfusion. 3. What is the only intravenous fluid compatible with blood products? - Normal saline 4. What actions should the nurse take if a hemolytic transfusion reaction occurs? - Turn off transfusion. Take temperature. Send blood being transfused to lab. Obtain urine sample. Keep vein patent with normal saline. 5. List 3 interventions for clients with a tendency to bleed. - Use a soft toothbrush, avoid salicylates, do not use suppositories. 6. Identify 2 sites, which should be assessed for infection in immunosuppressed clients. - Oral cavity and genital area. 7. Name 3 food sources of vitamin b12. - Glandular meats (liver), milk, green leafy vegetables. 8. Describe care of invasive catheters and lines. - Use strict aseptic technique. Change dressings 2 to 3 times/week or when soiled. Use caution when piggybacking drugs, check purpose of line and drug to be infused. Use lines for obtaining blood samples to avoid “sticking” client when possible. 9. List 3 safety precautions for the administration of antineoplastic chemotherapy. - Double check order with another nurse. Check for blood return prior to administration to ensure that medication does not go into tissue. Use a new IV site daily for peripheral chemotherapy. Wear gloves when handling the drugs, and dispose of waste in special containers to avoid contact with toxic substances. 10. Describe the use of Leucovorin. - Leucovorin is used as an antidote with methotrexate to prevent toxic reactions. 11. Describe the method of collecting the trough and peak blood levels of antibiotics. - Collection of trough: draw blood 30 minutes prior to administration of antibiotic. Collection of peak: draw blood 30 minutes after administration of antibiotic. 12. What is the characteristic cell found in Hodgkin’s disease? - Reed-Sternberg 13. List 4 nursing interventions for care of the client with Hodgkin’s disease. - Protect from infection. Observe for anemia. Encourage high-nutrient foods. Provide emotional support to client and family. 14. List 4 topics you would cover when teaching an immunosuppressed client about infection control. - Handwashing technique. Avoid infected persons. Avoid crowds. Maintain daily hygiene to prevent spread of microorganisms. REPRODUCTIVE SYSTEM: 1. What are the indications for a hysterectomy in the client who has fibromas? - Severe menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics, severe uterine enlargement causing pressure on other organs, severe low back and pelvic pain. 2. List the symptoms and conditions associated with cystocele. - Symptoms include incontinence/stress incontinence, urinary retention, and recurrent bladder infections. Conditions associated with cystocele include multiparity, trauma in childbirth, and aging. 3. What are the most important nursing interventions for the postoperative client who has had a hysterectomy with an A&P repair? - Avoid rectal temps and/or rectal manipulation; manage pain; and encourage early ambulation. 4. Describe the priority nursing care for the client who has had radiation implants. - Do not permit pregnant visitors or pregnant caretakers in room. Discourage visits by small children. Confine client to room. Nurse must wear radiation badge. Nurse limits time in room. Keep supplies and equipment within client’s reach. 5. What screening tool is used to detect cervical cancer? What are the American Cancer Society’s recommendations for women ages 30 to 70 with three consecutive normal results? - Pap smear. Women ages 30 to 70 with 3 consecutive normal results may have pap smear every 2 to 3 years. 6. Cite 2 nursing diagnoses for a client undergoing a hysterectomy for cervical cancer. - Altered body image related to uterine removal. Pain related to postoperative incision. 7. What are the 3 most important tools for early detection of breast cancer? How often should these tools be used? - Breast self-exam monthly; mammogram baseline at age 35 followed by exams every 1 to 2 years in 40s and every year after age 50; physical examination by a professional skilled in examination of the breast. 8. Describe 3 nursing interventions to help decrease edema post mastectomy. - Position arm on operative side on pillow. Avoid BP measurements, injections, or venipunctures in operative arm. Encourage hand activity and use. 9. Name 3 priorities to include in a discharge plan for the client who has had a mastectomy. - Arrange for Reach-to-Recovery visit. Discuss the grief process with the client. Have physician discuss with the client the reconstruction options. 10. What is the most common cause of nongonococcal urethritis? - Chlamydia trachomatis 11. What is the causative agent for syphilis? - Treponema pallidum (spirochete bacteria) 12. Malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD? - Trichomonas vaginalis 13. Which STD is characterized by remissions and exacerbations in both males and females? - Herpes Simplex Type II 14. Outline a teaching plan for the client with an STD. - Signs and symptoms of STD. Mode of transmission. Avoid sex while infected. Provide concise written instructions regarding treatment and request a return verbalization to ensure the client understands. Teach “safer sex” practices. BURNS: 1. List 4 categories of burns. - Thermal, radiation, chemical, electrical 2. Burn depth is a measure of severity. Describe the characteristics of superficial partial-thickness, deep partial-thickness, and full-thickness burns. - Superficial partial-thickness: 1st degree = pink to red skin (i.e., sunburn), slight edema, and pain relieved by cooling. Deep partial-thickness: 2nd degree = destruction of epidermis and upper layers of dermis; white or red, very edematous, sensitive to touch and cold air, hair does not pull out easily. Full-thickness: 3rd degree = total destruction of dermis and epidermis; reddened areas do not blanch with pressure, not painful, inelastic, waxy white skin to brown, leathery eschar. 3. Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of the burned client. - Stage I (Emergent phase): Replacement of fluids is titrated to urine output. Stage II (Acute phase): Maintain patent infusion site in case supplemental IV fluids are needed; heparin lock is helpful; may use colloids. Stage III (Rehabilitation phase): No extra fluids needed, but high-protein drinks are recommended. 4. Describe pain management of the burned client. - Administer pain medication, especially prior to dressing wound (usually Morphine 10 mg). Teach distraction/relaxation techniques. Teach use of guided imagery. 5. Outline admission care of the burned client. - Provide a patent airway as intubation may be necessary. Determine baseline data. Initiate fluid and electrolyte therapy. Administer pain medication. Determine depth and extent of burn. Administer tetanus toxoid. Insert NG tube. 6. Nutritional status is a major concern when caring for a burned client. List 3 specific dietary interventions used with burned clients. - High-calorie, high-protein, high-carbohydrate diet. Medications with juice or milk. NO “free” water. Tube feeding at night. Maintain accurate, daily calorie counts. Weigh client daily. 7. Describe the method of extinguishing each of the following burns: thermal, chemical and electrical. - Thermal: remove clothing, immerse in tepid water. Chemical: flush with water or saline. Electrical: separate client from electrical source. 8. List 4 signs of an inhalation burn. - Singed nasal hairs, circumoral burns; sooty or bloody sputum, hoarseness, and pulmonary signs including: assymetry of respirations, rales or wheezing. 9. Why is the burned client allowed NO “free” water? - Water may interfere with electrolyte balance. Client needs to ingest food products with highest biological value. 10. Describe an autograft. - Use of client’s own skin for grafting.