SAUNDERS HESI MED SURGEXAM
A burn client is receiving treatments of topical mafenide acetate
to the site of injury. The nurse monitors the client, knowing which
finding indicates that a systemic effect has occurred?
1. Hyperventilation
2. Elevated blood pressure
3. Local rash at the burn site
4. Local pain at the burn site - ...ANSWER✓✓✓1
Mafenide acetate is a carbonic anhydrase inhibitor and can
suppress renal excretion of acid, thereby causing acidosis.
Clients receiving this treatment should be monitored for signs of
an acid-base imbalance (hyperventilation). If this occurs, the
medication will probably be discontinued for 1 to 2 days. Options
3 and 4 describe local rather than systemic effects. Elevated
blood pressure may be expected from the pain that occurs with a
burn injury.
A client admitted to the hospital with a suspected diagnosis of
acute pancreatitis is being assessed by the nurse. Which
,assessment findings would be consistent with acute
pancreatitis? (SELECT ALL THAT APPLY.)
1. Diarrhea
2. Black, tarry stools
3. Hyperactive bowel sounds
4. Gray-blue color at the flank
5. Abdominal guarding and tenderness
6. Left upper quadrant pain with radiation to the back -
...ANSWER✓✓✓4, 5, 6
Grayish-blue discoloration at the flank is known as Grey-
Turner's sign and occurs as a result of pancreatic enzyme
leakage to cutaneous tissue from the peritoneal cavity. The client
may demonstrate abdominal guarding and may complain of
tenderness with palpation. The pain associated with acute
pancreatitis is often sudden in onset and is located in the
epigastric region or left upper quadrant with radiation to the
back. The other options are incorrect.
A client arrives at the emergency department following a burn
injury that occurred in the basement at home, and an inhalation
injury is suspected. What would the nurse anticipate to be
prescribed
for the client?
,1. 100% oxygen via an aerosol mask
2. Oxygen via nasal cannula at 6 L/minute
3. Oxygen via nasal cannula at 15 L/minute
4. 100% oxygen via a tight-fitting, nonrebreather face mask -
...ANSWER✓✓✓4
If an inhalation injury is suspected, administration
of 100% oxygen via a tight-fitting nonrebreather face mask is
prescribed until carboxyhemoglobin levels fall (usually below
15%). In inhalation injuries, the oropharynx is inspected for
evidence of erythema, blisters, or ulcerations. The need for
endotracheal intubation also is assessed. Administration of
oxygen by aerosol mask and cannula are incorrect and would not
provide the necessary oxygen supply needed for adequate tissue
perfusion for the client with a likely inhalation injury
A client arriving at the emergency department has experienced
frostbite to the right hand. Which finding would the nurse note on
assessment of the client's hand?
1. A pink, edematous hand
2. Fiery red skin with edema in the nail beds
3. Black fingertips surrounded by an erythematous rash
4. A white color to the skin, which is insensitive to touch -
...ANSWER✓✓✓4
, Assessment findings in frostbite include a white or
blue color; the skin will be hard, cold, and insensitive to touch. As
thawing occurs, flushing of the skin, the development of blisters
or blebs, or tissue edema appears. Options 1, 2, and 3 are
incorrect.
A client calls the emergency department and tells the nurse that
he came directly into contact with poison ivy shrubs. The client
tells the nurse that he cannot see anything on the skin and asks
the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rinsing several
times."
4. "It is not necessary to do anything if you cannot see anything
on your skin." - ...ANSWER✓✓✓3
When an individual comes in contact with a poison
ivy plant, the sap from the plant forms an invisible film on the
human skin. The client should be instructed to cleanse the area
by showering immediately and to lather the skin several times
and rinse each time in running water. Removing the poison ivy
sap will decrease the likelihood of irritation. Calamine lotion
may be one product recommended for use if dermatitis
A burn client is receiving treatments of topical mafenide acetate
to the site of injury. The nurse monitors the client, knowing which
finding indicates that a systemic effect has occurred?
1. Hyperventilation
2. Elevated blood pressure
3. Local rash at the burn site
4. Local pain at the burn site - ...ANSWER✓✓✓1
Mafenide acetate is a carbonic anhydrase inhibitor and can
suppress renal excretion of acid, thereby causing acidosis.
Clients receiving this treatment should be monitored for signs of
an acid-base imbalance (hyperventilation). If this occurs, the
medication will probably be discontinued for 1 to 2 days. Options
3 and 4 describe local rather than systemic effects. Elevated
blood pressure may be expected from the pain that occurs with a
burn injury.
A client admitted to the hospital with a suspected diagnosis of
acute pancreatitis is being assessed by the nurse. Which
,assessment findings would be consistent with acute
pancreatitis? (SELECT ALL THAT APPLY.)
1. Diarrhea
2. Black, tarry stools
3. Hyperactive bowel sounds
4. Gray-blue color at the flank
5. Abdominal guarding and tenderness
6. Left upper quadrant pain with radiation to the back -
...ANSWER✓✓✓4, 5, 6
Grayish-blue discoloration at the flank is known as Grey-
Turner's sign and occurs as a result of pancreatic enzyme
leakage to cutaneous tissue from the peritoneal cavity. The client
may demonstrate abdominal guarding and may complain of
tenderness with palpation. The pain associated with acute
pancreatitis is often sudden in onset and is located in the
epigastric region or left upper quadrant with radiation to the
back. The other options are incorrect.
A client arrives at the emergency department following a burn
injury that occurred in the basement at home, and an inhalation
injury is suspected. What would the nurse anticipate to be
prescribed
for the client?
,1. 100% oxygen via an aerosol mask
2. Oxygen via nasal cannula at 6 L/minute
3. Oxygen via nasal cannula at 15 L/minute
4. 100% oxygen via a tight-fitting, nonrebreather face mask -
...ANSWER✓✓✓4
If an inhalation injury is suspected, administration
of 100% oxygen via a tight-fitting nonrebreather face mask is
prescribed until carboxyhemoglobin levels fall (usually below
15%). In inhalation injuries, the oropharynx is inspected for
evidence of erythema, blisters, or ulcerations. The need for
endotracheal intubation also is assessed. Administration of
oxygen by aerosol mask and cannula are incorrect and would not
provide the necessary oxygen supply needed for adequate tissue
perfusion for the client with a likely inhalation injury
A client arriving at the emergency department has experienced
frostbite to the right hand. Which finding would the nurse note on
assessment of the client's hand?
1. A pink, edematous hand
2. Fiery red skin with edema in the nail beds
3. Black fingertips surrounded by an erythematous rash
4. A white color to the skin, which is insensitive to touch -
...ANSWER✓✓✓4
, Assessment findings in frostbite include a white or
blue color; the skin will be hard, cold, and insensitive to touch. As
thawing occurs, flushing of the skin, the development of blisters
or blebs, or tissue edema appears. Options 1, 2, and 3 are
incorrect.
A client calls the emergency department and tells the nurse that
he came directly into contact with poison ivy shrubs. The client
tells the nurse that he cannot see anything on the skin and asks
the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rinsing several
times."
4. "It is not necessary to do anything if you cannot see anything
on your skin." - ...ANSWER✓✓✓3
When an individual comes in contact with a poison
ivy plant, the sap from the plant forms an invisible film on the
human skin. The client should be instructed to cleanse the area
by showering immediately and to lather the skin several times
and rinse each time in running water. Removing the poison ivy
sap will decrease the likelihood of irritation. Calamine lotion
may be one product recommended for use if dermatitis
