Tissue Integrity

The nurse is supervising the care of a patient with a stage II pressure injury on the coccyx. Which intervention by the student nurse prompts the nurse to intervene with further education?

Following an apartment fire, the patient is brought to the emergency department by ambulance. The patient has third degree burns on the anterior bilateral lower legs and thighs, abdomen, and anterior bilateral arms. Soot is noted on the face; the patient appears to be speaking normally. Place the actions in the order the nurse performs them.

Following an explosion at a factory, the patient is brought by ambulance to the emergency department. The patient has soot on the face and around the mouth and is coughing up black sputum. He verbalizes severe pain in his leg and his voice is noted to be a hoarse whisper. Further assessment reveals full thickness burns to the arms and hands and partial thickness burns to the legs. Shrapnel appears to have been embedded in the patient’s thigh. While moving the leg to assess the inner thigh, a piece of shrapnel shifts and the patient begins bleeding profusely from the wound. The patient cries out in pain and requests pain relief. Which action does the nurse take first?

The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

The nurse in the burn ICU is caring for a patient with third degree burns over 33% of the body. Which assessment best indicates that fluid resuscitation has been adequate?

The patient sustained third degree burns to the entirety of bilateral hands and forearms 96 hours ago. Which nursing intervention is most important to ensure the patient is able to keep the hands?

The patient with third degree burns to bilateral lower legs is undergoing hydrotherapy to debride eschar tissue from the wounds. Prior to the procedure, the patient received a bolus of intravenous morphine in addition to the continuous infusion for pain control. During the procedure, the patient’s level of consciousness decreases to only rousable by painful stimuli. The patient’s temperature is 36.4°C, respiratory rate is 14 breaths per minute, heart rate is 82 bpm, and oxygen saturation is 93% on room air. The nurse ends the hydrotherapy session and contacts the provider to request which intervention?

The nurse anticipates administering cobalamin and folic acid to the patient presenting with which symptoms? Select all that apply.

The patient with cobalamin deficiency requires prompt and effective treatment to prevent which conditions? Select all that apply.  

At 48 hours after a bowel resection surgery for colon cancer, the colostomy is noted to be moist and purple. Which additional assessment is most important?  

During postoperative day 1 after a suprapubic prostatectomy, which assessment is most important for the drainage from the surgical wound?  

The nurse assesses the patient who has received continuous bladder irrigation (CBI) therapy since a transurethral resection of the prostate (TURP) 24 hours ago. Which assessment is the priority to report?  

The nurse is caring for the patient with prostate cancer and left-sided heart failure who underwent transurethral resection of the prostate (TURP) 12 hours ago. Clots are noted in the continuous bladder irrigation (CBI) outflow. Which action by the nurse is most appropriate?  

During a shift assessment 14 hours after a prostatectomy, the nurse notes bright red drainage in the continuous bladder irrigation (CBI) drainage bag. Which assessment is most important?  

The 3-year-old patient with acute pyelonephritis has the following orders:  Medications: 8 mg/kg ciprofloxacin IV q8h  Activity level: ambulatory as tolerated  Intravenous fluids: Infuse D5W with 0.25% NaCl via peripheral IV at 50 mL/h  Diet: Normal   The nurse is coordinating care for the patient with the unlicensed assistive personnel. Which statement by the UAP prompts further education by the nurse? 

The patient with psoriasis has been prescribed a keratolytic for management of cutaneous symptoms. The nurse instructs the patient to stop the medication and contact the provider if which symptoms occur? Select all that apply.   

The patient with severe psoriasis has been prescribed methotrexate. The nurse instructs the patient to schedule which follow-up tests? Select all that apply.   

The patient who has been prescribed methotrexate for the treatment of severe psoriasis has received medication teaching. Which statements indicate the teaching was effective? Select all that apply.

The nurse is providing preprocedural teaching for the patient scheduled for a cystectomy for bladder cancer. Which statement by the patient indicates teaching was effective? 

The patient with bladder cancer is scheduled for a cystectomy and creation of an internal ileal reservoir. Which statement by the patient indicates an understanding of the teaching?  

The patient has undergone a cystectomy with ureterosigmoidostomy. Which nursing interventions are included in the care plan? Select all that apply. 

The patient had an unsealed radiation source instilled into the uterus on Tuesday. On Friday, the patient has an episode of incontinence and requires a full linen change. How does the nurse dispose of the soiled linens? 

The nurse has provided self-care teaching to the patient who has undergone radiation therapy for breast cancer. Which action by the patient indicates a need for further teaching?  

Which intervention is appropriate for the patient receiving chemotherapy for breast cancer? 

The nurse is caring for the patient who is at the nadir for bone marrow suppression. Which order does the nurse clarify with the provider?  

The nurse assesses the patient with acute myelogenous leukemia after a bone marrow transplant. Which symptom concerns the nurse the most?

Which interventions does the nurse include in care for the patient who underwent a total pelvic exenteration for a cancer diagnosis one day ago? Select all that apply.  

The nurse is providing health promotion and disease prevention education to the 15-year-old patient receiving chemotherapy. Which statement does the nurse include?  

The 13-year-old girl is brought to the clinic for treatment of vaginal candidiasis for the 2nd time in 6 months. Which question is most helpful by the nurse?  

The 8-month-old patient has had 4 skin abscesses in the past 3 months that have required draining. Each abscess drains less than 5 mL non-purulent fluid. The infant appears well otherwise and the parents deny respiratory infections. The infant’s complete blood count shows an elevated white blood cell count without bands or segmented cells. Immunoglobulin levels are appropriate for the age of the infant. The patient has a positive nitroblue test. The nurse plans care to include which intervention? 

The 32-year-old patient presents complaining of severe itching on the arms that has gotten worse as her job has gotten more stressful. Upon assessment, the nurse observes erythematous lichen patches on the arms and in the antecubital fossa, where it is fissured and weeping. The nurse anticipates providing education about which medication?  

The 48-year-old patient is brought via ambulance to the emergency room after being found unresponsive by her son. She has a prescription for transdermal fentanyl patches for treatment of cancer pain related to her breast cancer that has metastasized to her pelvis. The patient’s heart rate is 72 bpm, respiratory rate is 4 breaths per minute, and her oxygen saturation is 88%. Her arterial blood gas results are: pH 7.21, PaCO₂ 72 mmHg, PaO₂ 74, HCO₃¯ 23. A thorough assessment reveals 2 fentanyl patches on the patient’s skin. The nurse advocates for which initial action?  

The nurse is preparing the otherwise healthy 54-year-old patient for a right knee replacement surgery and checks to see if the patient is allergic to which medication? 

The 50-year-old previously healthy patient complains of shortness of breath, especially on exertion or when laying down to sleep. She takes over-the-counter allergy medicine for seasonal allergies and melatonin to help her sleep sometimes. Her vital signs are heart rate of 64 bpm, respirations 22, oxygen saturation 99%, and blood pressure 114/68 mmHg. Her assessment is notable for crackles over the bilateral lung bases and a moderate diastolic apical murmur. Her electrocardiogram is normal. Her echocardiogram shows normal function of the left ventricle and severe stenosis of the mitral valve. The nurse provides which information to the patient?  

The 21-year-old intoxicated patient presents to the emergency department after sustaining an injury to the right hand during an altercation in a bar. He reports punching another individual in the face. An x-ray of the hand reveals a broken 4th proximal phalange and metacarpal. The corresponding knuckle has an open laceration. The nurse prepares the patient for which treatment?  

The patient with human immunodeficiency virus (HIV) presents with a disseminated rash. The nurse notes purple papules over the trunk, arms, and on mucous membranes. Some are scabbed. The patient’s CD4 count is 64. Although highly active antiretroviral therapy (HAART) has been prescribed, the patient reports being noncompliant because of intolerable side effects. The nurse suspects which infection is most responsible for this new rash? 

The nurse clarifies which order for the patient admitted with cellulitis caused by methicillin-resistant staphylococcus aureus?   

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mmHg. A rectal thermistor is inserted and aggressive cooling measures are instituted. After 30 minutes in the ice bath, the patient’s rectal temperature is 39.1°C and the ice is partially melted. Which action by the nurse is most important?