The nurse is caring for a patient with extensive burns. For which systemic responses to the burn should the nurse monitor the patient? (Select all that apply.)
a. Hypovolemia
b. Peptic ulceration
c. Decreased metabolism
d. Increased platelet function
e. Increased oxygen consumption
f. Depression of immunoglobulins
ANS: A, B, E, F
Following a major burn, increased capillary permeability leads to the leakage of plasma and proteins into the tissue, resulting in the formation of edema and loss of intravascular volume. C. Metabolic demands are very high in patients with burns, which in turn increases oxygen consumption. D. Intense heat decreases platelet function and half-life. With the skin destroyed, the body loses its first line of defense against infection. Major burns also cause a depression of the immunoglobulins IgA, IgG, and IgM. Peptic ulcers can occur due to decreased gastric motility and the stress response.
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A client is receiving chemotherapy as adjuvant therapy in the management of testicular cancer. The nurse also notes that the client is ordered filgrastim (Neupogen) and knows that the client is at greatest risk for which assessment finding?
A) Increased bruising B) Fever C) Pale color D) Decreased energy
The nurse is inspecting a client's chest and upper extremities. Which of the following would be the appropriate method for the nurse to assess these body areas?
1. Examine the right arm, the chest, and then the left arm. 2. Examine the left arm, the chest, and then the right arm. 3. Examine the left arm, the right arm, and then the chest. 4. Examine the chest and examine the arms at the conclusion of the exam as the client is re-dressing.
A client who is at least 65 years of age is asking the nurse how he will afford his hospitalization, which has now been extended, involving extremely expensive drugs. The best response by the nurse is:
1. "Don't worry. I'm sure everything will work out OK." 2. "You need to focus on recovering, not worrying about finances." 3. "Much of your care will be covered by Medicare." 4. "I'll have someone from the business office come and talk to you about your bill."
Cutting vegetables on the same cutting board that has been used to cut up raw chicken is an example of
a. saving time and energy resources. b. cross-contamination that could spread harmful bacteria. c. a potential problem only if the chicken was not refrigerated. d. a food safety problem if the vegetables and chicken are eaten at different meals.