A 28-year-old suffering from burns due to an automobile accident was rushed to the emergency room. Upon assessment, it is noted that his right arm and leg are burned. His burnt skin is red and white, moist, and bloody blisters are present. The patient complains of severe pain. Based on this description, what is the depth of injury?
• Superficial (1st degree): Red, dry, painful
• Superficial partial thickness (2nd degree): Red, clear blisters, moist, painful, blanches
• Deep partial thickness (2nd degree): Red and white, bloody blisters, moist, painful, less blanching
• Full thickness burn (3rd degree): White/Brown, dry, leathery, painless, no blanching
• 4th degree: Black, eschar, dry, painless, no blanching
A client diagnosed with heart failure has ineffective tissue perfusion related to decreased cardiac output. Which of the following nursing actions will monitor and improve tissue perfusion in this patient?
The nurse is assessing a patient with acromegaly. Which of the following signs can the nurse expect?
The nurse is admitting a patient suspected of having Goodpasture's syndrome. The nurse should be alert for signs of damage to the:
A patient is admitted to the medical unit for treatment of hydronephrosis. While performing an assessment, the nurse would expect:
The nurse is assigned to a patient at risk for the development of disseminated intravascular coagulation (DIC). Which of the following lab values should the nurse monitor?
A nurse is providing instructions to a patient with contact dermatitis. Which of the following interventions can be used to reduce pruritus and burning?
A patient with hypothyroidism is three days post-operative knee replacement when he becomes confused with marked hypothermia, and myxedema coma is suspected. What immediate actions should the nurse include?
Lower abdominal pain is a common complaint of patients diagnosed with urinary tract infections. Burning pain is experienced, especially upon urination. To help these patients prevent and relieve urinary discomfort, which of the following should be taught?
A nurse is providing instructions to a patient diagnosed with impetigo. Which of the following is important in the prevention of impetigo transmission?
A patient is seen in the clinic for multiple skin lesions that are indicative of herpes zoster (shingles). The physician asks the nurse to confirm diagnosis by performing which of the following diagnostic tests?
A nursing student is studying the body's response to an allergen. Which of the follow immunoglobulins is released during an allergic response?
The nurse is preparing a care plan for a patient with polymyositis. The nurse understands that the patient is at an elevated risk for:
A 49-year-old male with chronic renal failure will be starting hemodialysis. The nurse understands that hemodialysis is necessary for the patient because of the following:
You are caring for a client who just had a percutaneous renal biopsy. Which of the following nursing actions has the highest priority?
A nurse is suctioning a patient with a mechanical ventilator. Before suctioning, the nurse
A patient undergoing peritoneal dialysis is being assessed by the nurse for signs of peritonitis. Which of the following would indicate peritonitis?
A nurse is assessing a patient suspected of having herpes zoster (shingles). Which of the following lesion patterns should the nurse expect to observe?
A patient who sustained a back injury from a motor vehicle accident is currently in the left-side lying position. She is requesting the nurse to position her toward the right side, where the television is located. How would the nurse change the patient's position without causing further injury?
The nurse is caring for a patient with hepatic encephalopathy. When advising him on menu options, the nurse tells the patient to avoid:
The nurse is assessing a patient with atrial fibrillation and a rapid ventricular rate. The nurse would expect:
The nurse collects a urine sample from a patient with pyelonephritis. After the lab has completed the urinalysis, the nurse would expect which of the following abnormalities consistent with pyelonephritis?
A patient with pancreatitis is at risk for developing a paralytic ileus. Which of the following assessment data indicates this complication?
The nurse is caring for a patient with chronic renal failure (CRF) that has developed decreased erythropoietin synthesis. The nurse assesses the patient for:
A patient obtained multiple burns, with airway involvement, after a motor vehicle accident. Which nursing diagnosis is most important?
The nurse is caring for a client with hypopituitarism due to a tumor on the anterior pituitary. The nurse knows which of the following hormones to be secreted by the anterior pituitary gland?
The nurse is reviewing the lab results of a patient with Hashimoto's thyroiditis. Which of the following can the nurse expect?