week 2-3
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| show | Thermal
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| show | “Swelling is an expected inflammatory response of the body to a burn injury.”
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| 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? | show 🗑
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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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| show | Partial-thickness burn
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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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| What is the total 24-hour fluid requirement in milliliters for a 55-kg adult patient with 75% TBSA burned? | show 🗑
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| 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? | show 🗑
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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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| Which characteristics differentiate type III immune complex hypersensitivity from type II tissue-specific (cytotoxic) hypersensitivity? | show 🗑
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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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| Which goal reflects collaborative treatment for patients with a type III antigen-antibody complex hypersensitivity disorder, such as systemic lupus erythematosus? | show 🗑
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| 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? | show 🗑
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| show | Stop the antibiotic infusion
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| Which interventions will the nurse determine as correct for the patient experiencing a transfusion reaction? | show 🗑
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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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| The nurse determines which action will take priority upon recognizing a patient experiencing a febrile, non-hemolytic transfusion reaction? | show 🗑
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| The nurse determines which patient problem will take priority when the patient is experiencing a type III antigen-antibody complex hypersensitivity disorder? | show 🗑
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| Which theories characterize the mechanisms involved in autoimmunity? | show 🗑
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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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| 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? | show 🗑
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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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| Which nursing intervention does the nurse determine addresses the goal of “verbalizing strategies for effective self-care”? | show 🗑
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| What does the nurse determine is the most important reason for teaching patients on immune suppressive therapy to weigh weekly? | show 🗑
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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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| show | Increased doses of monoclonal antibodies
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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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| The nurse is reviewing the laboratory results for a patient who underwent kidney transplantation. Which finding warrants immediate health care provider notification? | show 🗑
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| show | Give immunosuppressant drugs
Assist the patient with ambulation
Administer intravenous (IV) fluids
Change the surgical site dressing as prescribed
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| show | Administer prophylactic antibiotics
Auscultate the patient’s lung sounds
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| 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? | show 🗑
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iobraztsov