2024 Hesi Milestone 1 VERIFIED SOLUTION WITH CORRECT ANSWERS

list 4 categories of burns - ANSWER Thermal, radiation, chemical, electrical Burn depth is a measure of severity. Describe the characteristics of superficial partial- thickness, deep partial-thickness, and full-thickness burns. - ANSWER -superficial partial thickness, first degree: pink to red skin (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. describe fluid management in the emergent phase, acute phase, and rehabilitation phase of the burned client - ANSWER -Stage 1 (emergency 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. Describe pain management of the burned client. - ANSWER Administer pain medication, especially before dressing wound. Teach distraction and relaxation techniques. Teach use of guided imagery. Outline admission care of the burned client. - ANSWER 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. nutritional status is a major concern when caring for a burned client. list three specific dietary interventions used with burned clients. - ANSWER high calorie, high protein, high carb diet, medications with juice or milk, no free water, tube feeding at night. Maintain accurate daily calorie counts, weigh client daily describe the method of extinguishing each of the following burns, thermal, chemical and electrical - ANSWER -Thermal: remove clothing, immerse in tepid water -Chemical: flush with water or saline -Electrical: separate client from electrical source list four signs of inhalation burn - ANSWER singed nasal hairs, circumoral burns, sooty/bloody sputum, hoarseness, pulmonary signs including asymmetrical of respirations, rales or wheezing Why is the burned client allowed no "free" water? - ANSWER Water may interfere with electrolyte balance. Client needs to ingest food products with highest biologic value Describe an autograft - ANSWER Use of clients own skin for grafting what are the indications for a hysterectomy in a client who has fibromas - ANSWER severe mennorhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics, severe uterine enlargement causing pressure on other organs, severe back and pelvic pain List the symptoms and conditions associated with a cystocele. - ANSWER symptoms include incontinence or stress incontinence, urinary retention and recurrent bladder infections. Conditions associated with cystocele include multiparty, trauma in childbirth and aging what are the most important nursing interventions for the post op client who has had a hysterectomy with an A&P repair - ANSWER avoid taking rectal temps and rectal manipulation, manage pain and encourage early ambulation describe the priority nursing care for a client who has radiation implants - ANSWER do not permit pregnant visitors or pregnant care takers in room. Discourage visits by small children. Confine client to room. Nurse must wear radiation badge, nurse limits time in room and keep supplies and equipment within clients reach 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 21? - ANSWER females under the age of 21 should not have Pap smear screenings Cite two nursing diagnoses for a client undergoing a hysterectomy for cervical cancer. - ANSWER altered body image related to uterine removal, pain related to post op incision what are the three most important tools for early detection of breast cancer? How often should these tools be used? - ANSWER breast self examination monthly, mammogram baseline at age 35 followed by examinations ever 1 to 2 years in 40's and every year after the age of 50, physical examination by a professional skilled in examination of the breast describe three nursing interventions to help decrease edema post mastectomy - ANSWER position arm on operative side on pillow, avoid BP measurements, injections, and venipuncture in operative arm and encourage hand activity/use name three priorities to include in a discharge plan for a client who has had a mastectomy - ANSWER arrange for reach to recovery visit, discuss the grief process with the client, have physician discuss with the client reconstruction options what is the most common cause of nongonococcal urethritis - ANSWER chlamydia trachoma's what is the causative organism of syphillis - ANSWER treponema pallidum (spirochete bacteria) malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD - ANSWER trichomonads vaginalis Which STD is characterized by remissions and exacerbations in both males and females? - ANSWER herpes simplex virus type 2 Outline a teaching plan for a client with an STD. - ANSWER Signs and symptoms 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. List three potential causes of anemia - ANSWER Diet lacking in iron, folate, or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic agents such as lead or insecticides. Write two nursing diagnoses for the client suffering from anemia. - ANSWER activity intolerance and ineffective tissue perfusion What is the only IV fluid compatible with blood products? - ANSWER normal saline what actions should the nurse take if a hemolytic transfusion occurs - ANSWER turn off transfusion, infuse normal saline using a new bag and new tubing, take temp, send blood being transfused to lab, obtain urine sample, keep vein patent with normal saline list three interventions for clients with a tendency to bleed - ANSWER use a soft toothbrush, avoid salicylates, do not use suppositories Identify two sites that should be assessed for infection and immunosuppressed clients - ANSWER oral cavity and genital area Name three food sources of vitamin B12 - ANSWER Glandular meats (liver), milk, green leafy vegetables Describe care of invasive catheters and lines - ANSWER 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. List three safety precautions for the administration of antineoplastic chemotherapy - ANSWER double check order with another nurse, check for blood return before admin 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 Describe the use of leucovorin. - ANSWER Leucovorin is used as an antidote with methotrexate to prevent toxic reactions. describe the method of collecting the trough and peak blood levels of antibiotics - ANSWER collection of trough: draw blood 30 mins before admin of antibiotic collection of peak: draw blood 30 mins after admin of antibiotics list four nursing interventions for care of the client with Hodgkin disease - ANSWER protect from infection, observe for anemia, encourage high nutrient foods, provide emotional support to client and family List four topics you would cover when teaching an immunosuppressed client about infection control. - ANSWER hand washing technique, avoid infected persons, avoid crowds, maintain daily hygiene to prevent spread of microorganisms what are the classifications of the commonly prescribed eye drops for glaucoma - ANSWER parasympathomimetic for pupillary constriction, beta adrenergic receptor blocking agents to inhibit formation of aqueous humor, carbonic anhydrase inhibitors to reduce aqueous humor production and prostaglandin agnostic to increase aqueous humor overflow