Exam 2

Question 1

The nurse is caring for a patient suspected of having renal dysfunction. When reviewing laboratory results for this patient, the nurse interprets the presence of which substances in the urine as most suggestive of pathology?

Answer 1

Glucose and protein

Question 2

A nurse knows that specific areas in the ureters have a propensity for obstruction. Prompt management of renal calculi is most important when the stone is located where?

Answer 2

In the ureteropelvic junction

Question 3

A patient with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?

Answer 3

Returning bicarbonate to the body’s circulation

Question 4

A patient has experienced excessive losses of bicarbonate and has subsequently developed an acid-base imbalance. How will this lost bicarbonate be replaced?

Answer 4

Renal tubular cells will generate new bicarbonate.

Question 5

A patients most recent laboratory findings indicate a glomerular filtration rate (GFR) of 58 mL/min. The nurse should recognize what implication of this diagnostic finding?

Answer 5

The patient is likely to have increased serum creatinine levels.

Question 6

A patient is scheduled for a diagnostic MRI of the lower urinary system. What pre-procedure education should the nurse include?

Answer 6

Relaxation techniques to apply during the test

Question 7

The nurse is caring for a patient who is going to have an open renal biopsy. What would be an important nursing action in preparing this patient for the procedure?

Answer 7

Keep the patient NPO prior to the procedure.

Question 8

A nurse is working with a patient who will undergo invasive urologic testing. The nurse has informed the patient that slight hematuria may occur after the testing is complete. The nurse should recommend what action to help resolve hematuria?

Answer 8

Increased fluid intake following the test

Question 9

A patient admitted to the medical unit with impaired renal function is complaining of severe, stabbing pain in the flank and lower abdomen. The patient is being assessed for renal calculi. The nurse recognizes that the stone is most likely in what anatomic location?

Answer 9

Ureter

Question 10

The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time?

Answer 10

With each meal

Question 11

The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)?

Answer 11

The patient’s average urine output has been 10 mL/hr for several hours.

Question 12

A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patient’s care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?

Answer 12

Excess fluid volume related to generalized edema

Question 13

A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurses care of this patient?

Answer 13

The patient’s disease is incurable and the nurse’s interventions will be supportive.

Question 14

The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patient’s siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder?

Answer 14

Polycystic kidney disease (PKD)

Question 15

A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase?

Answer 15

Dehydration

Question 16

The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurse’s role in caring for this patient? Select all that apply.

Answer 16

Providing emotional support for the family, Monitoring for complications, Participating in emergency treatment of fluid and electrolyte imbalances, and Providing nursing care for primary disorder (trauma)

Question 17

The nurse has identified the nursing diagnosis of risk for infection in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk?

Answer 17

Maintain aseptic technique when administering dialysate.

Question 18

A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patient’s peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply.

Answer 18

The cuffs are made of Dacron polyester, The cuffs stabilize the catheter, The cuffs prevent the dialysate from leaking, and The cuffs provide a barrier against microorganisms

Question 19

A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?

Answer 19

Assess for a thrill or bruit over the vascular access site each shift.

Question 20

The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patients output from surgical drains, the nurse should assess what parameters? Select all that apply.

Answer 20

Quantity of output, Color of the output, and Visible characteristics of the output

Question 21

A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient?

Answer 21

Drink liberal amounts of fluids.

Question 22

The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?

Answer 22

Teach the patient to perform pelvic floor muscle exercises.

Question 23

The nurse is caring for a patient with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a patient with an indwelling catheter?

Answer 23

Empty the drainage bag at least every 8 hours.

Question 24

A nurse on a busy medical unit provides care for many patients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which patient?

Answer 24

A patient who has Alzheimers disease and who is acutely agitated

Question 25

The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply.

Answer 25

Dietary history, Family history of renal stones, and Medication history

Question 26

A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient’s post-procedure care?

Answer 26

Strain the patient’s urine following the procedure.

Question 27

The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day?

Answer 27

2,000 mL

Question 28

A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1F (38.4C). How should the nurse best respond to the patient?

Answer 28

Tell the patient to report to the ED for further assessment.

Question 29

A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patients discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt?

Answer 29

Increasing fluid intake

Question 30

The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices?

Answer 30

Avoid using moisturizing soaps and body washes when cleaning the peristomal area.

Question 31

A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of disturbed body image. How can the nurse best address the effects of this urinary diversion on the patient’s body image?

Answer 31

Encourage the patient to speak openly and frankly about the diversion.

Question 32

A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed?

Answer 32

The widest part of the stoma

Question 33

The nurse is being trained to perform assessment screenings for abuse on patients who come into the walk-in clinic where the nurse works. Which of the following assessment questions is most appropriate?

Answer 33

Have you ever been forced into sexual activity?

Question 34

The nurse is taking the sexual history of an adolescent who has come into the free clinic. What question best assesses the patients need for further information?

Answer 34

What questions or concerns do you have about your sexual health?

Question 35

A nurse is collecting assessment data from a premenopausal patient who states that she does not have menses. What term should the nurse use to document the absence of menstrual flow?

Answer 35

Amenorrhea

Question 36

The nurse is planning the sexual assessment of a new adolescent patient. The nurse should include what assessment components? Select all that apply.

Answer 36

Physical examination findings, Laboratory results, and Health history

Question 37

A nurse presenting an educational event for a local community group is addressing premenstrual syndrome (PMS). What treatment guideline should the nurse teach this group?

Answer 37

Increase the frequency and intensity of exercise.

Question 38

A patient states that PMS that is significantly disrupting her quality of life and that conservative management has failed to produce relief. What pharmacologic treatment may benefit this patient?

Answer 38

An SSRI

Question 39

A 21-year-old woman has sought care because of heavy periods and has subsequently been diagnosed with menorrhagia. The nurse should recognize which of the following as the most likely cause of the patient’s health problem?

Answer 39

Cervical or uterine cancer

Question 40

A couple has come to the infertility clinic because they have been unable to get pregnant even though they have been trying for over a year. Diagnostic tests are planned for the woman to ascertain if ovulation is regular and whether her endometrium is adequately supported for implantation. What test would the nurse expect to have ordered for this woman?

Answer 40

Serum progesterone

Question 41

The nurse is working with a couple who is being evaluated for infertility. What nursing intervention would be most appropriate for this couples likely needs?

Answer 41

Referring them to appropriate community resources

Question 42

A 48-year-old woman presenting for care is seeking information about hormone therapy (HT) for the treatment of her perimenopausal symptoms. The patients need for relief from hot flashes and other symptoms will be weighed carefully against the increased risks of what complications of HT? Select all that apply.

Answer 42

Breast cancer, Cardiovascular disease, and Venous thromboembolism

Question 43

A 51-year-old woman is experiencing perimenopausal symptoms and expresses confusion around the possible use of hormone therapy (HT). She explains that her mother and aunts used HT and she is unsure why few of her peers have been prescribed this treatment. What should the nurse explain to the patient?

Answer 43

Research has shown that significant health risks are associated with HT.

Question 44

The nurse is assessing a patient who believes that she has recently begun menopause. What principle should inform the nurses interactions with this patient?

Answer 44

The nurse must carefully assess the patient’s feelings and beliefs surrounding menopause.

Question 45

A patient calls the clinic and tells the nurse she has thick white, curd-like discharge from her vagina. How should the nurse best interpret this preliminary data?

Answer 45

The patient may have a Candida species infection.

Question 46

While taking a health history on a 20-year-old female patient, the nurse ascertains that this patient is taking miconazole (Monistat). The nurse is justified in presuming that this patient has what medical condition?

Answer 46

Candidiasis

Question 47

A patient comes to the clinic complaining of a tender, inflamed vulva. Testing does not reveal the presence of any known causative microorganism. What aspect of this patient’s current health status may account for the patient’s symptoms of vulvitis?

Answer 47

The patient has type 1 diabetes.

Question 48

A 14-year-old is brought to the clinic by her mother. The mother explains to the nurse that her daughter has just started using tampons but is not yet sexually active. The mother states I am very concerned because my daughter is having a lot of stabbing pain and burning. What might the nurse suspect the problem is with the 14-year-old?

Answer 48

Vulvodynia

Question 49

When teaching patients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor?

Answer 49

HPV

Question 50

A female patient with HIV has just been diagnosed with condylomata acuminata (genital warts). What information is most appropriate for the nurse to tell this patient?

Answer 50

This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.

Question 51

A public health nurse is participating in a campaign aimed at preventing cervical cancer. What strategies should the nurse include is this campaign? Select all that apply.

Answer 51

Promotion of HPV immunization, Encouraging young women to delay first intercourse, Smoking cessation, and Using safer sex practices

Question 52

A patient diagnosed with cervical cancer will soon begin a round of radiation therapy. When planning the patients subsequent care, the nurse should prioritize actions with what goal?

Answer 52

Protecting the safety of the patient, family, and staff

Question 53

A 45-year-old woman has just undergone a radical hysterectomy for invasive cervical cancer. Prior to the surgery the physician explained to the patient that after the surgery a source of radiation would be placed near the tumor site to aid in reducing recurrence. What is the placement of the source of radiation called?

Answer 53

Brachytherapy

Question 54

A 25-year-old patient diagnosed with invasive cervical cancer expresses a desire to have children. What procedure might the physician offer as treatment?

Answer 54

Radical trachelectomy

Question 55

The nurse is caring for a patient with a diagnosis of vulvar cancer who has returned from the PACU after undergoing a wide excision of the vulva. How should this patient’s analgesic regimen be best managed?

Answer 55

Scheduled analgesia should be administered around-the-clock to prevent pain.

Question 56

A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?

Answer 56

Most cases of ovarian cancer are considered to be random, with no obvious causation.

Question 57

A patient is post-operative day 1 following a vaginal hysterectomy. The nurse notes an increase in the patient’s abdominal girth and the patient complains of bloating. What is the nurses most appropriate action?

Answer 57

Apply warm compresses to the patient’s lower abdomen.

Question 58

A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?

Answer 58

Count and inspect each perineal pad that the patient uses.

Question 59

The nurse leading an educational session is describing self-examination of the breast. The nurse tells the women’s group to raise their arms and inspect their breasts in a mirror. A member of the women’s group asks the nurse why raising her arms is necessary. What is the nurses best response?

Answer 59

It will help to observe for dimpling more closely.

Question 60

During a recent visit to the clinic a woman presents with erythema of the nipple and areola on the right breast. She states this started several weeks ago and she was fearful of what would be found. The nurse should promptly refer the patient to her primary care provider because the patient’s signs and symptoms are suggestive of what health problem?

Answer 60

Paget’s disease

Question 61

A patient has presented for her annual mammogram. The patient voices concerns related to exposure to radiation. What should the nurse teach the patient about a mammogram?

Answer 61

Radiation from a mammogram is equivalent to an hour of sunlight.

Question 62

A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurses best response?

Answer 62

An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment.

Question 63

A patient is being discharged home from the ambulatory surgery center after an incisional biopsy of a mass in her left breast. What are the criteria for discharging this patient home? Select all that apply.

Answer 63

Patient must have someone to accompany her home, Patient must understand activity restrictions, and Patient must understand care of the biopsy site

Question 64

The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?

Answer 64

Non-tenderness

Question 65

A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patients lump is cancerous?

Answer 65

A nonmobile mass with irregular edges

Question 66

The nurse is performing a comprehensive health history of a patient who is in her 50s. The nurse should identify what risk factor that may increase this patients risk for breast cancer?

Answer 66

The patient gave birth to her first child at age 38.

Question 67

A nurse has assessed that a patient is not yet willing to view her mastectomy site. How should the nurse best assist the patient is developing a positive body image?

Answer 67

Provide the patient with encouragement in an empathetic and thoughtful manner

Question 68

A patient has been discharged home after a total mastectomy without reconstruction. The patient lives alone and has a home health referral. When the home care nurse performs the first scheduled visit to this patient, what should the nurse assess? Select all that apply.

Answer 68

Adherence to the exercise plan, Overall psychological functioning, and Integrity if surgical drains

Question 69

A nurse is teaching a 53-year-old man about prostate cancer. What information should the nurse provide to be facilitate the early identification of prostate cancer?

Answer 69

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly

Question 70

A nurse is performing an admission assessment on a 40-year-old man who has been admitted for outpatient surgery on his right knee. While taking the patients family history, he states, “My father died of prostate cancer at age 48.” The nurse should instruct him on which of the following health promotion activities?

Answer 70

The patient should have PSA levels drawn regularly

Question 71

A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?

Answer 71

The patient should avoid close contact with his daughter for 2 months

Question 72

A patient is 24 hours postoperative following prostatectomy and the urologist has ordered continuous bladder irrigation. What color of output should the nurse expect to find in the drainage bag?

Answer 72

Light pink

Question 73

A nursing student is learning how to perform sexual assessments using the PLISSIT model. According to this model, the student should begin an assessment by doing which of the following?

Answer 73

Asking the patient if he is willing to discuss sexual functioning

Question 74

A clinic nurse is providing pre-procedure education for a man who will undergo a vasectomy. Which of the following measures will enhance healing and comfort? Select all that apply.

Answer 74

Wearing a scrotal support garment and Using a sitz bath

Question 75

A patient presents to the emergency department with paraphimosis. The physician is able to compress the glans and manually reduce the edema. Once the inflammation and edema subside, what is usually indicated?

Answer 75

Circumcision

Question 76

A 75-year-old male patient is being treated for phimosis. When planning this patient’s care, what health promotion activity is most directly related to the etiology of the patient’s health problem?

Answer 76

Teaching the patient about the importance of hygiene

Question 77

An uncircumcised 78-year-old male has presented at the clinic complaining that he cannot retract his foreskin over his glans. On examination, it is noted that the foreskin is very constricted. The nurse should recognize the presence of what health problem?

Answer 77

Phimosis

Question 78

A 57-year-old male comes to the clinic complaining that when he has an erection his penis curves and becomes painful. The patient’s diagnosis is identified as severe Peyronie’s disease. The nurse should be aware of what likely treatment modality?

Answer 78

Surgery

Question 79

A 35-year-old man is seen in the clinic because he is experiencing recurring episodes of urinary frequency, dysuria, and fever. The nurse should recognize the possibility of what health problem?

Answer 79

Chronic bacterial prostatitis

Question 80

A 55-year-old client with a history of type 1 diabetes presents at the clinic reporting erectile dysfunction. The physician prescribes tadalafil to be taken 2-hour before sexual intercourse. The nurse reviews the client’s history prior to instructing the client on the use of this medication. What disorder will contraindicate the use of tadalafil?

Answer 80

Retinopathy

Question 81

Following a recent history of dyspareunia and lower abdominal pain, a client has received a diagnosis of pelvic inflammatory disease (PIDS). When providing health education related to self-care, the nurse should address what topics? Select all that apply.

Answer 81

Use of condoms to prevent infecting others and Appropriate use of antibiotics

Question 82

When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?

Answer 82

The palms of the hands

Question 83

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin?

Answer 83

D

Question 84

An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many spots on her skin., what would be an appropriate response by the nurse?

Answer 84

As people age, they normally develop uneven pigmentation in their skin

Question 85

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?

Answer 85

By protecting older adults against shearing injuries

Question 86

A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?

Answer 86

Diminished protection of tissues and organs

Question 87

A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion?

Answer 87

Pustule

Question 88

A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?

Answer 88

Wheal

Question 89

Assessment of a patient’s leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?

Answer 89

Ulcer

Question 90

A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (Warfarin). For what skin lesion should the nurse monitor this patient?

Answer 90

Ecchymosis

Question 91

The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?

Answer 91

Cherry angiomas

Question 92

A nurse is assessing the skin of a patient who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the patient’s health history, the nurse should identify what comorbidity as increasing the patient’s vulnerability to skin infections?

Answer 92

Diabetes

Question 93

A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction?

Answer 93

Moderately positive

Question 94

A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen?

Answer 94

Patch testing

Question 95

A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What should be the most appropriate question to ask this patient and her family?

Answer 95

Has she eaten any new foods today?

Question 96

A patient presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition?

Answer 96

Tzanck smear

Question 97

A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risks of basal cell carcinoma (BCC)?

Answer 97

Teaching participants to limit their sun exposure

Question 98

A patient presents at the free clinic with a black, wart-like lesion on his face, stating, I’ve done some research, and I’m pretty sure I have malignant melanoma. Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis?

Answer 98

The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable

Question 99

While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patient’s ear. The nurse knows that this lesion is consistent with what type of skin cancer?

Answer 99

Malignant melanoma

Question 100

A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include?

Answer 100

Deficient Knowledge about Early Signs of Melanoma

Question 101

A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment?

Answer 101

Wide excision

Question 102

A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?

Answer 102

Anticipate the need for, and administer, appropriate analgesic medications

Question 103

A nurse educator is teaching a group of medical nurses about Kaposis sarcoma. What would the educator identify as characteristics of endemic Kaposis sarcoma? Select all that apply.

Answer 103

Affects people predominantly in the eastern half of Africa, Affects men more than women, and Can progress to lymphadenopathic forms

Question 104

A nurse is providing care for a patient who has developed Kaposi’s sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body?

Answer 104

Endothelial cells lining small blood vessels

Question 105

A 35-year-old kidney transplant comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposis sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposis Sarcoma?

Answer 105

Immunosuppression-related

Question 106

A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse expect?

Answer 106

Classic Kaposis sarcoma

Question 107

A 30-year-old male patient has just returned from the operating room after having a flap done following a motorcycle accident. The patient’s wife asks the nurse about the major complications following this type of surgery. What would be the nurses best response?

Answer 107

The major complication is when the blood supply fails and the tissue in the flap dies

Question 108

A patient comes to the dermatology clinic requesting the removal of a port-wine stain on his right cheek. The nurse knows that the procedure especially useful in treating cutaneous vascular lesions such as port-wine stains is what?

Answer 108

Laser treatment

Question 109

A client with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?

Answer 109

Surgical excision

Question 110

A nurse practitioner is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?

Answer 110

Benzoyl Peroxide and erythromycin (Benzamycin)

Question 111

A patients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?

Answer 111

Lactated Ringers

Question 112

The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care?

Answer 112

Acute

Question 113

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?

Answer 113

Prevention of venous thromboembolism

Question 114

A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?

Answer 114

That’s something that you and your doctor will likely talk about after your scars mature

Question 115

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member?

Answer 115

His body has consumed his fat deposits for fuel because his calorie intake is lower than normal

Question 116

A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?

Answer 116

Continuously

Question 117

A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?

Answer 117

That’s something that you and your doctor will likely talk about after your scars mature

Question 118

Your older adult patient has been diagnosed with urosepsis and has a temperature of 103.4F. you should be aware that the oxygen demands of the patients body would change in which direction and why?

Answer 118

Increase due to an increase in metabolism

Question 119

The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk?

Answer 119

Encourage physical activity and range of motion exercises

Question 120

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?

Answer 120

Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

Question 121

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?

Answer 121

Assess the patients peripheral pulses distal to the dressing

Question 122

A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?

Answer 122

Apply a layer of ointment approximately 1/16 inch thick

Question 123

A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response?

Answer 123

Inform the primary care provider promptly because the graft may need to be removed

Question 124

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What should the nurse in the ED receiving the call instruct the father to do?

Answer 124

Immerse the child in a cool bath

Question 125

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to “cool the burn”. How should the nurse cool the burn?

Answer 125

Wrap cool towels around the affected extremity intermittently