SAUNDERS HESI MED SURG
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 - ANS-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 - ANS-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 - ANS-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 - ANS-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." -
ANS-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
develops. The client does not need to be seen in the emergency department at this
time.
\A client had a new colostomy created 2 days earlier and is beginning to pass
malodorous flatus from the stoma. What is the correct interpretation by the nurse?
,1. This is a normal, expected event.
2. The client is experiencing early signs of ischemic bowel.
3. The client should not have the nasogastric tube removed.
4. This indicates inadequate preoperative bowel preparation. - ANS-1
As peristalsis returns following creation of a colostomy, the client begins to pass
malodorous flatus. This indicates returning bowel function and is an expected event.
Within 72 hours of surgery, the client should begin passing stool via the colostomy.
Options 2, 3, and 4 are incorrect interpretations.
\A client has a new prescription for metoclopramide. On review of the chart, the
nurse identifies that this medication can be safely administered with which condition?
1. Intestinal obstruction
2. Peptic ulcer with melena
3. Diverticulitis with perforation
4. Vomiting following cancer chemotherapy - ANS-4
Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a
gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction,
hemorrhage, or perforation. It is used in the treatment of vomiting after surgery,
chemotherapy, or radiation.
\A client has a prescription to take guaifenesin. The nurse determines that the client
understands the proper administration of this medication if the client states that he or
she will perform which action?
1. Take an extra dose if fever develops
2. Take the medication with meals only
3. Take the tablet with a full glass of water
4. Decrease the amount of daily fluid intake - ANS-3
Guaifenesin is an expectorant and should be taken with a full glass of water to
decrease the viscosity of secretions. Extra doses should not be taken. The client
should contact the health care provider if the cough lasts longer than 1 week or is
accompanied by fever, rash, sore throat, or persistent headache. Fluids are needed
to decrease the viscosity of secretions. The medication does not have to be taken
with meals.
\A client has an as needed prescription for loperamide hydrochloride. For which
condition should the nurse administer this medication?
1. Constipation
2. Abdominal pain
3. An episode of diarrhea
4. Hematest-positive nasogastric tube drainage - ANS-3
, Loperamide is an antidiarrheal agent. It is used to manage acute and chronic
diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be
used to reduce the volume of drainage from an ileostomy. It is not used for the
conditions in options 1, 2, and 4.
\A client has an as-needed prescription for ondansetron. For which condition(s)
should the nurse administer this medication?
1. Paralytic ileus
2. Incisional pain
3. Urinary retention
4. Nausea and vomiting - ANS-4
Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as
well as nausea and vomiting associated with chemotherapy. The other options are
incorrect reasons for administering this medication.
\A client has been admitted with chest trauma after a motor vehicle crash and has
undergone subsequent intubation. The nurse checks the client when the
high-pressure alarm on the ventilator sounds, and notes that the client has absence
of breath sounds in the right upper lobe of the lung. The nurse immediately assesses
for other signs of which condition?
1. Right pneumothorax
2. Pulmonary embolism
3. Displaced endotracheal tube
4. Acute respiratory distress syndrome - ANS-1
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with
respiration, asymmetrical chest expansion, and diminished or absent breath sounds
on the affected side. Pneumothorax can cause increased airway pressure because
of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary
embolism are not characterized by absent breath sounds. An endotracheal tube that
is inserted too far can cause absent breath sounds, but the lack of breath sounds
most likely would be on the left side because of the degree of curvature of the right
and left mainstem bronchi.
\A client has been diagnosed with hyperthyroidism. The nurse monitors for which
signs and symptoms indicating a complication of this disorder? (SELECT ALL THAT
APPLY.)
1. Fever
2. Nausea
3. Lethargy
4. Tremors
5. Confusion
6. Bradycardia - ANS-1, 2, 4, 5
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 - ANS-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 - ANS-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 - ANS-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 - ANS-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." -
ANS-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
develops. The client does not need to be seen in the emergency department at this
time.
\A client had a new colostomy created 2 days earlier and is beginning to pass
malodorous flatus from the stoma. What is the correct interpretation by the nurse?
,1. This is a normal, expected event.
2. The client is experiencing early signs of ischemic bowel.
3. The client should not have the nasogastric tube removed.
4. This indicates inadequate preoperative bowel preparation. - ANS-1
As peristalsis returns following creation of a colostomy, the client begins to pass
malodorous flatus. This indicates returning bowel function and is an expected event.
Within 72 hours of surgery, the client should begin passing stool via the colostomy.
Options 2, 3, and 4 are incorrect interpretations.
\A client has a new prescription for metoclopramide. On review of the chart, the
nurse identifies that this medication can be safely administered with which condition?
1. Intestinal obstruction
2. Peptic ulcer with melena
3. Diverticulitis with perforation
4. Vomiting following cancer chemotherapy - ANS-4
Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a
gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction,
hemorrhage, or perforation. It is used in the treatment of vomiting after surgery,
chemotherapy, or radiation.
\A client has a prescription to take guaifenesin. The nurse determines that the client
understands the proper administration of this medication if the client states that he or
she will perform which action?
1. Take an extra dose if fever develops
2. Take the medication with meals only
3. Take the tablet with a full glass of water
4. Decrease the amount of daily fluid intake - ANS-3
Guaifenesin is an expectorant and should be taken with a full glass of water to
decrease the viscosity of secretions. Extra doses should not be taken. The client
should contact the health care provider if the cough lasts longer than 1 week or is
accompanied by fever, rash, sore throat, or persistent headache. Fluids are needed
to decrease the viscosity of secretions. The medication does not have to be taken
with meals.
\A client has an as needed prescription for loperamide hydrochloride. For which
condition should the nurse administer this medication?
1. Constipation
2. Abdominal pain
3. An episode of diarrhea
4. Hematest-positive nasogastric tube drainage - ANS-3
, Loperamide is an antidiarrheal agent. It is used to manage acute and chronic
diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be
used to reduce the volume of drainage from an ileostomy. It is not used for the
conditions in options 1, 2, and 4.
\A client has an as-needed prescription for ondansetron. For which condition(s)
should the nurse administer this medication?
1. Paralytic ileus
2. Incisional pain
3. Urinary retention
4. Nausea and vomiting - ANS-4
Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as
well as nausea and vomiting associated with chemotherapy. The other options are
incorrect reasons for administering this medication.
\A client has been admitted with chest trauma after a motor vehicle crash and has
undergone subsequent intubation. The nurse checks the client when the
high-pressure alarm on the ventilator sounds, and notes that the client has absence
of breath sounds in the right upper lobe of the lung. The nurse immediately assesses
for other signs of which condition?
1. Right pneumothorax
2. Pulmonary embolism
3. Displaced endotracheal tube
4. Acute respiratory distress syndrome - ANS-1
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with
respiration, asymmetrical chest expansion, and diminished or absent breath sounds
on the affected side. Pneumothorax can cause increased airway pressure because
of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary
embolism are not characterized by absent breath sounds. An endotracheal tube that
is inserted too far can cause absent breath sounds, but the lack of breath sounds
most likely would be on the left side because of the degree of curvature of the right
and left mainstem bronchi.
\A client has been diagnosed with hyperthyroidism. The nurse monitors for which
signs and symptoms indicating a complication of this disorder? (SELECT ALL THAT
APPLY.)
1. Fever
2. Nausea
3. Lethargy
4. Tremors
5. Confusion
6. Bradycardia - ANS-1, 2, 4, 5
