week 2-3
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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? | show 🗑
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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? | show 🗑
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show | “I will check my patient hourly to make sure that he does not experience an inflammatory response from his burns.”
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A nurse is caring for a patient with a first-degree thermal burn injury. Which symptom can the nurse expect to see on assessment? | show 🗑
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What is the proper classification for a thermal burn involving only the epidermis and superficial structures of the dermis? | show 🗑
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show | The Lund-Browder chart considers the age of the patient in calculation of TBSA.
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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? | show 🗑
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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? | show 🗑
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show | 16500 4mlx55x75
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show | Insert urinary catheter to monitor intake and output
Monitor oxygen status and provide supplemental oxygen as needed
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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 | show 🗑
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show | “You seem to be very anxious. Would you like to talk about how you’re feeling?”
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Type I: Anaphylaxis Wheezing, dysrhythmias, cyanosis Type II: Acute hemolytic reaction Fever, hypotension, chills | show 🗑
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show | 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
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show | Pollen is the offending allergen.
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What is the rationale behind the collaborative treatment, immunotherapy? | show 🗑
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show | Immune suppression to halt disease progression
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show | Thrombocytopenia
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show | Stop the antibiotic infusion
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show | 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.
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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? | show 🗑
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show | Discontinue the infusion.
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show | Controlling current acute exacerbation
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show | Leakage of protected self-antigens
Epitope immune system evasion
Loss of T suppressor function
Failure of T cell programming
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show | Reddish facial rash
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Which diagnostic test differentiates the level of autoimmune disease activity from the presence of disease? | show 🗑
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The nurse determines that collaborative goals for a patient with an autoimmune disorder are met when which findings are present? | show 🗑
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show | Decreased lymphocyte count
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show | Reduced swelling
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show | Consult with the health care provider.
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Which step does the nurse determine is first when caring for a patient with an autoimmune disorder? | show 🗑
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show | Continue activities and being productive, seeking assistance if needed.
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show | monitor for weight change
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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? | show 🗑
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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? | show 🗑
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show | Patient who had a recent bone marrow transplant
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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? | show 🗑
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show | “The use of chemotherapy medications can play an important role in preventing organ rejection.”
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What will the nurse include in the discharge teaching for a patient who has received a prescription for prednisone after liver transplantation? | show 🗑
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Which assessment component will the nurse check when administering a dose of lymphocyte immune globulin to a patient with acute rejection? | show 🗑
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show | Intake of 2000 mL and output of 800 mL in 24 hours
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Which interventions are appropriate for the nurse to include in the plan of care for a patient who underwent organ transplantation 2 days ago? | show 🗑
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show | Administer prophylactic antibiotics
Auscultate the patient’s lung sounds
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show | Administering the immunosuppressant medications as prescribed
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Created by:
iobraztsov