HESI
Chapter 4 Review Q/A
Respiratory System
1. List four common symptoms of pneumonia the nurse might note on physical
examination.
- Tachypnea
- Fever w/ chills
- Productive cough
- Bronchial breath sounds
2. State four nursing interventions for assisting the client to cough productively.
- Encourage deep breathing
- Increase fluid intake to 3L/day
- Use humidity to loosen secretions
- Suction airway to stimulate coughing
3. What symptom of pneumonia might the nurse expect to see in an older client?
- Confusion
- Lethargy
- Anorexia
- Rapid Respiratory Rate
4. How does the nurse prevent hypoxia during suctioning?
- Deliver 100% O2 (hyperinflating) before and after each endotracheal
suctioning
5. During mechanical ventilation, what are three major nursing interventions?
- Monitor client’s respiratory status and secure connections; establish a
communication mechanism with the client; keep airway clear by coughing
and suctioning
6. When examining a client with emphysema, what physical findings is the nurse likely to
see?
- Barrel chest, dry or productive cough, decreased breath sounds, dyspnea,
crackles in lung fields
7. What is the most common risk factor associated with lung cancer?
- Smoking (cigarettes and marijuana)
8. Describe why preoperative nursing care is important to include for a client undergoing a
laryngectomy.
- Involve family and client in manipulation of tracheostomy equipment before
surgery; plan acceptable communication methods; refer to speech
pathologist; discuss rehabilitation program.
9. List five nursing interventions after chest tube insertion.
- Maintain a dry occlusive dressing on chest tube. Keep all tubing connections
tight and taped. Monitor client’s clinical status. Encourage the client to
breathe deeply periodically. Monitor the fluid drainage, and mark the time of
measurement and the fluid level.
10. What immediate action should the nurse take when a chest tube becomes disconnected
from a bottle or suction apparatus? What should the nurse do if a chest tube is
inadvertently removed from the chest?
- Place the end of the tube in a sterile water container at 2-cm level. Apply
occlusive dressing and notify HCP stat.
11. What instructions should be given to a client after radiation?
- Do not wash off lines; wear soft cotton garments; avoid use of powders and
creams on radiation site.
12. What precautions are required for clients with TB when placed on respiratory isolation?
- A mask for anyone entering room; private room (negative pressured); client
must wear mask if leaving room.
13. List four components for teaching clients with tuberculosis.
- Cough into tissues and dispose of immediately in special bags. Long-term
need for daily medication. Good hand-washing technique. Report symptoms
of deterioration, such as blood in secretions.
Renal System
1. Differentiate between ARF and CRF.
- ARF: often reversible, abrupt deterioration of kidney function.
- CRF: irreversible, slow deterioration of kidney function characterized by
increasing BUN and creatinine. Eventually dialysis is required.
2. During the oliguric phase of renal failure, protein should be severely restricted. What is
the rationale for this restriction?
- Toxic metabolites that accumulate in the blood (urea, creatinine) are derived
mainly from protein catabolism.
3. Identify two nursing interventions for the client on hemodialysis.
- DO NOT take BP or perform venipuncture on the arm w/ AV shunt, fistula, or
graft. Assess access site for thrill and bruit.
4. A client in renal failure asks why antacids are being given. How should the nurse reply?
- Calcium and albumin antacids bind phosphates and help keep phosphates
from being absorbed into bloodstream, thereby preventing rising phosphate
levels; must be taken with meals.
5. List four essential elements of a teaching plan for clients with frequent UTIs.
- Fluid intake 3L/day; good hand washing; void every 2 to 3 hours during
waking hours; take all prescribed medications; wear cotton undergarments.
6. What are the most important nursing interventions for clients with possible renal
calculi?
- Straining all urine is the most important intervention. Other interventions
include accurate I&O documentation and administering analgesics as
needed.
7. What discharge instructions should be given to a client who has had urinary calculi?
-
Maintain high fluid intake of 3 to 4L/day. Pursue follow-up care (stones tend
to recur). Follow prescribed diet based on calculi content. Avoid supine
position.
8. After TURP, hematuria should subside by what postoperative day?
- The fourth day
9. After the urinary catheter is removed in the TURP client, what are three priority nursing
actions?
- Continued strict I&O. Continued observations for hematuria. Inform client
burning and frequency is a possible outcome and may last for up to a week.
10. After kidney surgery, what are the primary assessments the nurse should make?
- Respiratory status (breathing is guarded because of pain); circulatory status
(the kidney is very vascular and excessive bleeding can occur); pain
assessment; urinary assessment (most important, assessment of urinary
output)
Cardiovascular System
1. How do clients experiencing angina describe that pain?
- Described as squeezing, heavy, burning, radiates to left arm or shoulder,
transient or prolonged
2. Develop a teaching plan for a client prescribed nitroglycerin.
- Take at first sign of anginal pain. Take no more than three, 5 minutes apart.
Call for emergency attention if no relief in 10 minutes.
3. List the parameters of BP for diagnosing HTN.
- >140/90
4. Differentiate between essential and secondary HTN.
- Essential HTN: no known cause
- Secondary HTN: develops in response to an identifiable mechanism.
5. Develop a teaching plan for a client taking antihypertensive medications.
- Explain how and when to take medication, reason for medication, necessity
of compliance, need to follow-up visits while on medication, need for certain
laboratory tests, and vital signs parameters while initiating therapy.
6. Describe intermittent claudication.
- Pain related to PVD; the pain occurs with exercise and disappears with rest.
7. Describe the nurses discharge instructions to a client with venous PVD.
- Keep extremities elevated when sitting, rest at first sign of pain, keep
extremities warm (but do not use heating pad), change position often, avoid
crossing legs, wear unrestrictive clothing.
8. What is often the underlying cause of an AAA?
- Atherosclerosis
9. What laboratory values should be monitored daily in a client with thrombophlebitis who
is undergoing anticoagulant therapy?
- PTT, PT, Hgb, Hct, platelets
10. When do PVCs present a grave danger?
-
When they begin to occur more often than once in 10 beats, occur in twos or
threes, land near the T wave, or take on multiple configurations
11. Differentiate between the symptoms of left-sided cardiac failure and right-sided cardiac
failure.
- Left-sided failure results to pulmonary congestion due to backup of
circulation in the left ventricle.
- Right-sided failure results in peripheral congestion due to backup of
circulation in the right ventricle.
12. List three symptoms of digitalis toxicity.
- Dysrhythmias, headache, nausea and vomiting
13. What conditions increases the likelihood that digitalis toxicity will occur?
- Hypokalemia (which is more common when diuretics and digitalis
preparations are given together)
14. What lifestyle changes can the client who is at risk for HTN initiate to reduce the
likelihood of becoming hypertensive?
- Cease cigarette smoking, if applicable; control weight; exercise regularly; and
maintain a low-fat, low-cholesterol diet.
15. What immediate actions should the nurse implement when a client is having an MI?
- Administer O2 by nasal cannula at 2 to 5L/min; ensure patent IV or start an IV
to deliver emergency medication; take measures to alleviate pain and anxiety
(administer PRN pain medications and antianxiety medications); place the
client on immediate strict bed rest to lower O2 demands on heart.
16. What symptoms should the nurse expect to find in a client with hypokalemia?
- Dry mouth and thirst; drowsiness and lethargy, muscle weakness and aches,
and tachycardia.
17. Bradycardia is defined as an HR below ______ bpm. Tachycardia is defined as an HR
above ____ bpm.
- Bradycardia HR below 60 bpm
- Tachycardia HR above 100 bpm
18. What precautions should clients with valve disease take before invasive procedures or
dental work?
- Take prophylactic antibiotics
Gastrointestinal System
1. List four nursing interventions for the client with a hiatal hernia.
- Sit up while eating and for 1 hour after eating; Eat frequent, small meals.
Eliminate foods that are problematic.
2. List three categories of medications used in the treatment of PUD.
- Antacids, H2 receptor blockers, mucosal healing agents, proton pump
inhibitors
3. List the symptoms of upper and lower GI bleeding.
- Upper GI: melena, hematemesis, tarry stools
- Lower GI: bloody stools, tarry stools
- Common to both: tarry stools
4. What bowel sound disruptions occur with intestinal obstruction?
- Early mechanical obstruction: high-pitched sounds
- Late mechanical obstruction: diminished or absent bowel sounds
5. List four nursing interventions for postoperative care of a client with a colostomy.
- Irrigate daily at same time; use warm water for irrigations; wash around
stoma with mild soap and water after each ostomy bag change; ensure that
pouch opening extends at least 1/8inch around the stoma.
6. List the common clinical manifestations of jaundice.
- Scleral icterus (yellow sclera), dark urine, chalky or clay-colored stools.
7. What are the common food intolerances for clients with cholelithiasis?
- Fried, spicy, and fatty foods.
8. List the five symptoms indicative of colon cancer.
- Rectal bleeding, change in bowel habits, sense of incomplete evacuation,
abdominal pain with nausea, weight loss.
9. In a client with cirrhosis, it is imperative to prevent further bleeding and observe for
bleeding tendencies. List six relevant nursing interventions.
- Avoid injections; use small-bore needs for IV insertion; maintain pressure for
5 minutes on all venipuncture sites; use electric razor; use soft-bristle
toothbrush for mouth care; check stools and emesis for occult blood.
10. What is the main side effect of lactulose, which is used to reduce ammonia levels in
clients with cirrhosis?
- Diarrhea
11. List four groups who have a high risk for contracting hepatitis.
- Homosexual males, IV drug users, those who have had recent ear piercing or
tattooing, and health care workers
12. How should the nurse administer pancreatic enzymes?
- Give with meals or snacks. Powder forms should be mixed w/ fruit juices.
Endocrine System
1. What diagnostic test is used to determine thyroid activity?
- T3, T4
2. What condition results from all treatments for hyperthyroidism?
- Hypothyroidism, requiring thyroid replacement
3. State three symptoms of hyperthyroidism and three symptoms of hypothyroidism.
- Hyperthyroidism: weight loss, heat intolerance, diarrhea
- Hypothyroidism: fatigue, cold intolerance, weight gain
4. List five important teaching aspects for clients who are beginning corticosteroid therapy.
- Continue medication until weaning plan is begun by physician; monitor
serum potassium, glucose, and sodium frequently; weight daily, and report
gain of >5lb/week; monitor BP and pulse closely; teach symptoms of Cushing
syndrome.
5. Describe the physical appearance of clients who have Cushing syndrome.
-
Moon face, obesity in trunk, buffalo hump in back, muscle atrophy, and thin
skin
6. Which type of diabetes always require insulin replacement?
- Type 1
7. Which type of diabetes sometimes require no medication?
- Type 2
8. List five symptoms of hyperglycemia.
- Polydipsia, polyuria, polyphagia, weakness, weight loss
9. List five symptoms of hypoglycemia.
- Hunger, lethargy, confusion, tremors or shakes, sweating
10. Name the necessary elements to include in teaching a client newly diagnosed with
diabetes.
- The underlying pathophysiology of the disease; its management and
treatment regimen; meal planning; exercise program; insulin administration;
sick day management; symptoms of hyperglycemia (not enough insulin);
symptoms of hypoglycemia (too much insulin, too much exercise, not enough
food); foot care
11. The nurse is in a situation where there is no premixed insulin. In fewer than 10 steps,
describe the method of drawing up a mixed dose of insulin (regular with NPH).
- Identify the prescribed dose and type of insulin per physician order; store
unopened insulin in refrigerator. Opened insulin vials may be kept at room
temperature. Draw up regular insulin first; rotate injection sites; may reuse
syringe by recapping and storing in refrigerator.
12. Identify the peak action time of the following types of insulin: rapid-acting regular
insulin, intermediate-acting insulin and long-acting insulin.
- Rapid-acting regular insulin: 2 to 4 hours; immediate-acting insulin: 6 to 12
hours; long-acting insulin: 14 to 20 hours
13. When preparing a client with diabetes for discharge, the nurse teaches the client the
relationship between stress, exercise, bedtime snacking, and glucose balance. State the
relationships among each of these.
- Stress and stress hormones usually increase glucose production and increase
insulin need. Conversely, exercise may increase the chance of a hypoglycemic
reaction; therefore, the client should always carry a fast-acting source of
carbohydrate, such as glucose tablets or hard candies, when exercising.
14. When making rounds at night, the nurse notes that a client prescribed insulin is
complaining of a headache, slight nausea, and minimal trembling. The client’s hand is
cool and moist. What is the client most likely experiencing?
- Hypoglycemia/insulin reaction
15. Identify five foot-care interventions that should be taught to a client with diabetes.
- Check feet daily, and report any breaks, sores, or blisters to HCP; wear wellfitting shoes; never go barefoot or wear sandals; never personally remove
corns or calluses; cut or file nails straight across; wash feet daily with mild
soap and warm water.
Musculoskeletal System
1. Differentiate between rheumatoid arthritis and OA in terms of joint involvement.
- Rheumatoid arthritis occurs bilaterally. OA occurs asymmetrically.
2. Identify the categories of drugs commonly used to treat arthritis.
- NSAIDs, of which salicylates are the cornerstone of treatment, and
corticosteroids (used when arthritic symptoms are severe)
3. Identify pain relief interventions for clients with arthritis.
- Warm, moist heat (compresses, baths, showers); diversionary activities
(imaging, distraction, self-hypnosis, biofeedback); and medications
4. What measures should the nurse encourage female clients to take to prevent
osteoporosis?
- Possible estrogen replacement after menopause, high calcium and vitamin D
intake beginning in early adulthood, calcium supplements after menopause,
and weight-bearing exercise
5. What are the common side effects of salicylates?
- GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation
6. What is the priority nursing intervention used with clients taking NSAIDs?
- Administer or teach client to take drugs with food or milk.
7. List three of the most common joints that are replaced.
- Hip, knee, finger
8. Describe postoperative residual limb (stump) care (after amputation) for the first 48
hours.
- Elevate residual limb (stump) for first 24 hours. Do not elevate residual limb
(stump) after 48 hours. Keep residual limb (stump) in extended position, and
turn client to prone position three times a day to prevent flexion contracture.
9. Describe nursing care for the client who is experiencing phantom pain after amputation.
- Be aware that phantom pain is real and will eventually disappear. Administer
pain medication; phantom pain responds to medication.
10. A nurse discovers that a client who is in traction for a long bone fracture has a slight
fever, is short of breath, and is restless. What does the client most likely have?
- A fat embolism, which is characterized by hypoxemia, respiratory distress,
irritability, restlessness, fever, and petechiae
11. What are the immediate nursing actions if fat embolization is suspected in a client with
a fracture or other orthopedic condition?
- Notify physician stat, draw blood gases, administer O2 according to blood gas
results, assist with endotracheal intubation and treatment of respiratory
failure.
12. List three problems associated with immobility.
- Venous thrombosis, urinary calculi, skin integrity problems
13. List three nursing interventions for the prevention of thromboembolism in immobilized
clients with musculoskeletal problems.
- Passive ROM exercise, elastic stocking, and elevation of foot of bed 25
degrees to increase venous return
Neurologic System
1. What are the classifications of the commonly prescribed eye drops for glaucoma?
- Parasympathomimetic for pupillary constriction; beta adrenergic receptorblocking agents to inhibit formation of aqueous humor; carbonic anhydrase
inhibitors to reduce aqueous humor production; and prostaglandin agonists
to increase aqueous humor outflow
2. Identify two types of hearing loss.
- Conductive (transmission of sound to inner ear is blocked) and sensorineural
(damage to eighth cranial nerve)
3. Write four nursing interventions for the are of the blind person and four nursing
interventions for the care of the deaf person.
- Care of blind: announce presence clearly, call by name, orient carefully to
surroundings, guide by walking in front of client with his or her hand in your
elbow. Care of deaf: reduce distraction before beginning conversation, look
and listen to client, give client full attention if he or she is a lip reader, face
client directly.
4. In your own words, describe the Glasgow Coma Scale.
- An objective assessment of the LOC based on a score of 3 to 15, with scores
of 7 or less indicative of coma
5. State four independent nursing interventions to maintain adequate respiration, airway,
and oxygenation in the unconscious client.
- Position for maximum ventilation (prone or semiprone and slightly to one
side); insert airway if tongue is obstructing; suction airway efficiently;
monitor arterial PO2 and PCO2; and hyperventilate with 100% O2 before
suctioning.
6. Who is at risk for stroke?
- Persons with histories of HTN, previous TIAs, cardiac disease (atrial flutter or
fibrillation), diabetes, or oral contraceptive use; and older adults
7. Complications of immobility include the potential for thrombus development. State
three nursing interventions to prevent thrombi.
- Frequent ROM exercises, frequent (every 2 hours) position changes, and
avoidance of positions that decrease venous return
8. List four rationales for the appearance of restlessness in the unconscious client.
- Anoxia, distended bladder, cover bleeding or a return to consciousness
9. What nursing interventions prevent corneal drying in a comatose client?
- Irrigation of eyes PRN with sterile prescribed solution, application of
ophthalmic ointment every 8 hours, close assessment for corneal ulceration
or drying
10. When can a comatose client on IV hyperalimentation begin to receive tube feedings
instead?
- When peristalsis resumes as evidenced by active bowel sounds, passage of
flatus or bowel movement
11. What is the most important principle in a bowel management program for a client with
neurologic deficits?
- Establishment of regularity
12. Define stroke.
- A disruption of blood supply to a part of the brain, which results in sudden
loss of brain function
13. A client with a diagnosis of stroke presents with symptoms of aphasia and right
hemiparesis but no memory or hearing deficit. In what hemisphere has the client
suffered a lesion?
- Left
14. What are the symptoms of spinal shock?
- Hypotension, bladder and bowel distention, total paralysis, lack of sensation
below lesion
15. What are the symptoms of autonomic dysreflexia?
- HTN, bladder and bowel distention, total paralysis, lack of sensation below
lesion
16. What are the most important indicator of increased ICP?
- A change in the level of responsiveness
17. What vital signs changes are indicative of increased ICP?
- Increased BP, widening pulse pressure, increased or decreased pulse,
respiratory irregularities, and temperature increase
18. A neighbor calls the neighborhood nurse stating that his very hyperactive dog knocked
him hard to the floor. He is wondering what symptoms would indicate the need to visit
an emergency department. What should the nurse tell him to do?
- Call his physician now and inform him or her of the fall. Symptoms needing
medical attention would include vertigo, confusion or any subtle behavioral
change, headache, vomiting, ataxia (imbalance), or seizure.
19. What activities and situations that increase ICP should be avoided?
- Change in bed position, extreme hip flexion, endotracheal suctioning,
compression of jugular veins, coughing, vomiting, and straining of any kind
20. What is the action of hyperosmotic agents (osmotic diuretics) used to treat ICP?
- They dehydrate the brain and reduce cerebral edema by holding water in the
renal tubules to prevent reabsorption and by drawing fluid from the
extravascular spaces into the plasma.
21. Why should narcotics be avoided in clients with neurologic impairment?
- Narcotics mask the level of responsiveness and pupillary responses.
22. Headache and vomiting are symptoms of many disorders. What characteristics of these
symptoms would alert the nurse to refer a client to a neurologist?
- Headache that is more severe upon awakening, and vomiting not associated
with nausea are symptoms of a brain tumor.
23. How should the head of the bed be positioned for post craniotomy clients with
infratentorial lesions?
- Supratentorial: elevated; infratentorial: flat
24. Is MS thought to occur because of an autoimmune process?
- Yes
25. Is paralysis always a consequence of spinal cord injury?
- No
26. What types of drugs are used in the treatment of myasthenia gravis?
- Anticholinesterase drugs, which inhibit the action of cholinesterase at the
nerve endings to promote the accumulation of acetylcholine at receptors;
this should improve neuronal transmission to muscle.
Hematology and Oncology
1. List three potential causes of anemia.
- Diet lacking in iron, folate, or vitamin B12, use of salicylates, thiazides,
diuretics; exposure to toxic agents, such as lead or insecticides
2. What is the only IV fluid compatible with blood products?
- Normal saline
3. What actions should the nurse take if a hemolytic transfusion reaction occurs?
- Turn off transfusion. Infuse normal saline using a new bag and new tubing.
Take temperature. Send blood being transfused to laboratory. Obtain urine
sample. Keep vein patent with normal saline.
4. List three interventions for clients with a tendency to bleed.
- Use of a soft toothbrush, avoid salicylates, do not use suppositories.
5. Identify two sites that should be assessed for infection in immunosuppressed clients.
- Oral cavity and genital area.
6. Name three food sources of vitamin B12.
- Glandular meats (livers), milk, green leafy vegetables
7. Describe care of invasive catheters and lines.
- Use strict aseptic technique. Change dressings two or three times per week
or when soiled. Use caution when piggybacking drugs; check purpose of line
and drug to be infused. When possible, use lines to obtain blood samples to
avoid “sticking” client.
8. List three safety precautions for the administration of antineoplastic chemotherapy.
- Double check order with another nurse. Check for blood return before
administration to ensure that medication does not go into tissue. Use a new
IV site daily for peripheral chemotherapy. Wear gloves when handling the
drugs and dispose of waste in special containers to avoid contact with toxic
substances.
9. Describe the use of leucovorin.
- Leucovorin is used as an antidote with methotrexate to prevent toxic
reactions.
10. Describe the method of collecting the trough and peak blood levels of antibiotics.
- Collection of trough: Draw blood 30 minutes before administration of
antibiotics; collection of peak: Draw blood 30 minutes after administration of
antibiotic.
11. List four nursing interventions for care of the client with Hodgkin disease.
-
Protect from infection. Observe for anemia. Encourage high-nutrient foods.
Provide emotional support to client and family.
12. List four topics you would cover when teaching an immunosuppressed client about
infection control.
- Hand washing technique. Avoid infected persons. Avoid crowds. Maintain
daily hygiene to prevent spread of microorganisms.
Reproductive System
1. What are the indications for a hysterectomy in a client who has fibromas?
- Severe menorrhagia leading to anemia, severe dysmenorrhea requiring
narcotic analgesics, severe uterine enlargement causing pressure on other
organs, severe low back and pelvic pain
2. List the symptoms and conditions associated with cystocele.
- Symptoms include incontinence or stress incontinence, urinary retention,
and recurrent bladder infections. Conditions associated with cystocele
include multi-parity, trauma in childbirth, and aging.
3. What are the most important nursing interventions for the postoperative client who has
had a hysterectomy with an A&P repair?
- Avoid taking rectal temperatures and rectal manipulation; manage pain; and
encourage early ambulation
4. Describe the priority nursing care for a client who has had radiation implants.
- Do not permit pregnant visitors or pregnant caretakers in room. Discourage
visits by small children. Confine client to room. Nurse must wear radiation
badge. Nurse limits time in the room. Keep supplies and equipment within
client’s reach.
5. What screening tool is used to detect cervical cancer? What are the American Cancer
Society’s recommendations for the Pap smear screening for females under age 21?
- Females under the age of 21 should not have Pap smear screenings.
6. What are the most important tools for early detection of breast cancer? How often
should these tools be used?
- Women should report any changes in their breasts to the HCP. A baseline
mammography should be performed for women between 35 and 40 years of
age with a mammogram every 1 to 2 years for women between ages 40 and
44. An annual mammogram should be performed for women between ages
45 and 54.
7. Describe three nursing interventions to help decrease edema postmastectomy.
- Position arm an operative side on pillow. Avoid BP measurements, injections,
and venipunctures in operative arm. Encourage hand activity and use.
8. Name three priorities to include in a discharge plan for a client who has had a
mastectomy.
- Arrange for Reach for Recovery to visit. Discuss the grief process with the
client. Have physician discuss with client the reconstruction options.
9. What is the most common cause of nongonococcal urethritis?
- Chlamydia trachomatis
10. What is the causative organism of syphilis?
- Treponema pallidum (spirochete bacteria)
11. Malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD?
- Trichomonas vaginalis
12. Which STD is characterized by remissions and exacerbations in both males and females?
- Herpes simplex type 2
13. Outline a teaching plan for a client with an STD.
- S/S of STD; mode of transmission; avoiding sex while infected; providing
concise written instructions regarding treatment, and requesting a return
verbalization to ensure that the client understands; teaching safer sex
practices
Burns
1. List four categories of burns.
- Thermal, radiation, chemical, electrical
2. Burn depth is a measure of severity. Describe the characteristics of superficial partialthickness; deep partial-thickness, and full-thickness burns.
- Superficial partial-thickness, first degree: pink to red skin (e.g., sunburn),
slight edema, and pain relieved by cooling
- Deep partial-thickness, second degree: destruction of epidermis and upper
layers of dermis; white or red, very edematous, sensitive to touch and cold
air, hair does not pull out easily
- Full-thickness, third degree: total destruction of dermis and epidermis;
reddened areas do not blanch with pressure; not painful; inelastic; waxy
white skin to brown, leathery eschar
3. Describe fluid management in the emergent phase, acute phase, and rehabilitation
phase of the burned client.
- Stage 1 (emergent phase): Replacement of fluids is titrated to urine output.
- Stage 2 (acute phase): Patent infusion site is maintained in case
supplemental IV fluids are needed; saline lock is helpful; colloids may be used
- Stage 3 (rehabilitation phase): No extra fluids are needed but high protein
drinks are recommended.
4. Describe pain management of the burned client.
- Administer pain medication, especially before dressing wound. Teach
distraction and relaxation techniques. Teach use of guided imagery.
5. Outline admission care of the burned client.
- Provide a patent airway because intubation may be necessary. Determine
baseline data. Initiate fluid and electrolyte therapy. Administer pain
medication. Determine depth and extent of burn. Administer tetanus toxoid.
Insert NG tube.
6. Nutritional status is a major concern when caring for a burned client. List three specific
dietary interventions used with burned clients.
-
High-calorie, high-protein, high-carbohydrate diet; medications with juice or
milk; no “free” water; tube feeding at night. Maintain accurate, daily calorie
counts. Weigh client daily.
7. Describe the method of extinguishing each of the following burns: thermal, chemical,
and electrical.
- Thermal: Remove clothing, immerse in tepid water.
- Chemical: Flush with water or saline.
- Electrical: Separate client from electrical source.
8. List four signs of an inhalation burn.
- Singed nasal hairs, circumoral burns; sooty or bloody sputum, hoarseness,
and pulmonary signs, including asymmetry of respirations, rales, or wheezing
9. Why is the burned client allowed no “free” water?
- Water may interfere with electrolyte balance. Client needs to ingest food
products with highest biologic value.
10. Describe an autograft.
- Use of clients own skin for grafting.