HESI MILESTONE 1 REVIEW 2024-2025 |COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS ( VERIFIED ANSWERS 0 ALREADY
GRADED A+.
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 -
ANSWERavoid 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
CORRECT DETAILED ANSWERS ( VERIFIED ANSWERS 0 ALREADY
GRADED A+.
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 -
ANSWERavoid 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
