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BSN 266
week 2-3
Question | Answer |
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A nurse is caring for a patient who spilled boiling soup on her legs. Which type of burn will the nurse see? | Thermal |
A family member of a patient with a severe facial burn asks the nurse why the patient’s face is swollen. Which statement made by the nurse is appropriate? | “Swelling is an expected inflammatory response of the body to a burn injury.” |
A student nurse is caring for a patient with severe thermal burns. Which statement made by the student nurse to the charge nurse indicates that additional teaching is needed? | “I will check my patient hourly to make sure that he does not experience an inflammatory response from his burns.” |
A nurse is caring for a patient with a first-degree thermal burn injury. Which symptom can the nurse expect to see on assessment? | Blanching with pressure |
What is the proper classification for a thermal burn involving only the epidermis and superficial structures of the dermis? | Partial-thickness burn |
When calculating the total body surface area (TBSA) affected by a burn, the nurse knows that the Lund-Browder chart is considered more accurate than the rule of nines for which reason? | The Lund-Browder chart considers the age of the patient in calculation of TBSA. |
A nurse is caring for a newly admitted patient in the emergent phase after a severe electrical burn. Which provider orders should the nurse question? | Obtain an ECG in 8 hours Administer PO pain medication |
A nurse is caring for a patient with a chemical burn to the left extremity who is in the rehabilitative phase of burn management. Which order would the nurse anticipate from the health care provider? | Provide patient education on wound care |
What is the total 24-hour fluid requirement in milliliters for a 55-kg adult patient with 75% TBSA burned? | 16500 4mlx55x75 |
The nurse is caring for a patient who was just transported by EMS to the hospital for burns to the legs, chest, arms, and face. Which nursing interventions are appropriate at this time? | Insert urinary catheter to monitor intake and output Monitor oxygen status and provide supplemental oxygen as needed |
A patient is admitted to the burn center with burns to the neck and chest after a gasoline explosion at work. Emergency transport reported wheezing in the upper lung fields. Upon initial assessment, the nurse notes no current wheezing and | Contact the health care provider and prepare for emergency intubation. |
A patient with facial burns frequently asks the nurse, “When will I look normal again?” Which is an appropriate response by the nurse? | “You seem to be very anxious. Would you like to talk about how you’re feeling?” |
Type I: Anaphylaxis Wheezing, dysrhythmias, cyanosis Type II: Acute hemolytic reaction Fever, hypotension, chills | Type III: Post streptococcal glomerulonephritis Hypertension, proteinuria, edema Type IV: Contact dermatitis Vesiculated blisters, itching, burning |
Which characteristics differentiate type III immune complex hypersensitivity from type II tissue-specific (cytotoxic) hypersensitivity? | Triggered frequently by an event such as infection Immune complexes deposited in vessels and organs Complexes form in blood from circulating antigens and antibodies Neutrophils try to phagocytize immune complexes |
How will the nurse interpret the results of the enzyme-linked immunosorbent assay (ELISA) ordered for a patient with a type I hypersensitivity disorder? | Pollen is the offending allergen. |
What is the rationale behind the collaborative treatment, immunotherapy? | Antigen exposure over time replaces IgE-specific antibodies with IgE-blocking antibodies, reducing lymphocyte sensitivity. |
Which goal reflects collaborative treatment for patients with a type III antigen-antibody complex hypersensitivity disorder, such as systemic lupus erythematosus? | Immune suppression to halt disease progression |
Which finding associated with use of corticosteroids as collaborative treatment for type I hypersensitivity (allergy) will the nurse report to the patient’s health care provider? | Thrombocytopenia |
Which action will the nurse take first upon entering the room of a patient who has an intravenous antibiotic running and is experiencing an anaphylactic reaction? | Stop the antibiotic infusion |
Which interventions will the nurse determine as correct for the patient experiencing a transfusion reaction? | Stop the infusion, but not the IV. Maintain IV patency with normal saline. Notify the health care provider immediately. Prepare to administer prescribed medications. Return blood and tubing to the laboratory. |
The statement “I may be able to control some things that trigger my disorder, but not all” from a patient with a type III immune-complex hypersensitivity disorder supports meeting which goal? | Avoiding triggers when possible |
The nurse determines which action will take priority upon recognizing a patient experiencing a febrile, non-hemolytic transfusion reaction? | Discontinue the infusion. |
The nurse determines which patient problem will take priority when the patient is experiencing a type III antigen-antibody complex hypersensitivity disorder? | Controlling current acute exacerbation |
Which theories characterize the mechanisms involved in autoimmunity? | Leakage of protected self-antigens Epitope immune system evasion Loss of T suppressor function Failure of T cell programming |
Which classic characteristic is most often noted in patients with the autoimmune disorder systemic lupus erythematosus? | Reddish facial rash |
Which diagnostic test differentiates the level of autoimmune disease activity from the presence of disease? | Serum complement |
The nurse determines that collaborative goals for a patient with an autoimmune disorder are met when which findings are present? | Decreased patient symptoms Patient enters remission Exacerbation prevented |
The nurse determines the patient’s prescribed Basilximab (monoclonal antibody) is acting to prevent T cell activation based on which finding? | Decreased lymphocyte count |
The nurse determines the effectiveness of placing cold on the autoimmune patient’s acutely inflamed knee after noting which finding? | Reduced swelling |
Which action will the nurse take after noting the newly elevated blood urea nitrogen (BUN) and serum creatinine on the laboratory report of a patient who has an autoimmune disorder, fever, and chills? | Consult with the health care provider. |
Which step does the nurse determine is first when caring for a patient with an autoimmune disorder? | Determining patient needs |
Which nursing intervention does the nurse determine addresses the goal of “verbalizing strategies for effective self-care”? | Continue activities and being productive, seeking assistance if needed. |
What does the nurse determine is the most important reason for teaching patients on immune suppressive therapy to weigh weekly? | monitor for weight change |
The nurse determines that which action takes priority for a newly admitted patient with an autoimmune disorder who is acutely ill with fever and pain? | Facilitating periods of uninterrupted rest |
The nurse is caring for a patient who underwent kidney transplantation 8 hours ago. Which finding would indicate that the patient is developing hyperacute rejection? | Decreased to no urine output |
Which patient would the nurse expect to be at highest risk for developing graft-versus-host disease (GVHD)? | Patient who had a recent bone marrow transplant |
A patient who underwent organ transplantation 2 months ago is admitted to the hospital with acute rejection. Which order would the nurse anticipate from the health care provider? | Increased doses of monoclonal antibodies |
A female transplant recipient asks the nurse to explain why she is receiving a cytotoxic drug even though she does not have cancer. What is the nurse’s best response? | “The use of chemotherapy medications can play an important role in preventing organ rejection.” |
What will the nurse include in the discharge teaching for a patient who has received a prescription for prednisone after liver transplantation? | “Weigh yourself daily.” “Take daily calcium supplements.” “Do not suddenly stop taking the drug.” |
Which assessment component will the nurse check when administering a dose of lymphocyte immune globulin to a patient with acute rejection? | Heart rate |
The nurse is reviewing the laboratory results for a patient who underwent kidney transplantation. Which finding warrants immediate health care provider notification? | Intake of 2000 mL and output of 800 mL in 24 hours |
Which interventions are appropriate for the nurse to include in the plan of care for a patient who underwent organ transplantation 2 days ago? | Give immunosuppressant drugs Assist the patient with ambulation Administer intravenous (IV) fluids Change the surgical site dressing as prescribed |
The nurse is caring for a patient who received an organ transplant 3 days ago. Which nursing assessments and interventions will decrease the risk for infection? | Administer prophylactic antibiotics Auscultate the patient’s lung sounds |
The nurse is caring for a patient who had a liver transplant 3 months ago. Which nursing intervention can prevent acute rejection in this patient? | Administering the immunosuppressant medications as prescribed |