The Emergency Department (ED) nurse is assessing an 80-year-old patient who has superficial, partial thickness and deep partial thickness scald burns on bilateral anterior and posterior hands and forearms. The nurse estimates that the total body surface Tire CTBSA) burned is 27%. What should the nurse include in the emergent plan of care?

Start fluid resuscitation and prepare for transport co a Burn Center

Apply petroleum based antibiotic cream to the affected areas

Cover the burns with saline soaked gauze and medicated ointment

Clean the wounds with soap and room temperature water

Answer and Explanation

The Correct Answer is A

A) Start fluid resuscitation and prepare for transport to a Burn Center:
In this case, the patient has burns that cover 27% of the total body surface area (TBSA), which falls within the moderate to severe range for burn injuries. Fluid resuscitation is critical to prevent hypovolemic shock, a common complication of severe burns due to fluid loss. The "rule of nines" or Lund-Browder chart can be used to calculate the amount of fluids needed. The patient should also be prepared for transport to a specialized burn center, where advanced care can be provided for wound management, infection prevention, and long-term rehabilitation.

B) Apply petroleum-based antibiotic cream to the affected areas:
Although topical antibiotics are an essential part of burn care to prevent infection, petroleum-based ointments are typically not recommended in the emergent phase of burn management. Applying such creams could potentially trap heat and cause further tissue damage, and petroleum-based products can be occlusive, which may interfere with wound healing.
C) Cover the burns with saline-soaked gauze and medicated ointment:
While it is important to keep burns covered to prevent infection, the use of saline-soaked gauze and medicated ointments are more appropriate after initial fluid resuscitation and stabilization of the patient. Immediate burn care focuses on preventing further injury and initiating fluid resuscitation. Saline-soaked gauze is typically used in a controlled setting, like in a burn unit, and the patient's wounds should not be excessively covered with ointment during the emergent phase.

D) Clean the wounds with soap and room temperature water:
In burn management, cleaning the wounds with soap and water can disrupt the skin's protective barrier, particularly in the emergent phase. It is important to gently clean the wounds with sterile saline or an antiseptic solution and avoid harsh cleansers. Soap and water might cause irritation, exacerbate pain, and increase the risk of infection. The focus should be on stabilizing the patient and initiating proper wound management with sterile techniques.

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Correct Answer is C

Explanation

A) A Rhinovirus infection can cause cancer of the cervix
Rhinovirus is primarily associated with the common cold and respiratory infections, not with cervical cancer. The risk factors for cervical cancer are related to persistent infections with certain strains of the human papillomavirus (HPV), especially high-risk types like HPV-16 and HPV-18, which can lead to cervical dysplasia and, eventually, cervical cancer.

B) Eating foods high in fat and taking birth control pills are risk factors
While diet and certain medications may influence overall health, eating foods high in fat and taking birth control pills are not primary risk factors for cervical cancer. Research has shown that certain hormonal contraceptives (especially long-term use) may slightly increase the risk of cervical cancer, but the most significant and well-established risk factor is HPV infection, not fat intake or birth control use.

C) The earlier the age of sexual activity and the more partners, the greater the risk
The major risk factor for cervical cancer is persistent infection with high-risk HPV. Early initiation of sexual activity and having multiple sexual partners increase the risk of HPV infection, which is a leading cause of cervical cancer. HPV is transmitted through sexual contact, and early exposure to the virus, as well as repeated exposure to multiple partners, increases the likelihood of acquiring a high-risk strain of HPV.

D) Having yearly Pap smears will protect you from developing cancer
While Pap smears (Pap tests) are important for detecting precancerous changes (such as dysplasia) or early-stage cervical cancer, they do not prevent cancer. Pap smears can help identify abnormal cell changes that can be treated before they develop into cancer, but they do not protect against the development of cancer.

A. hypoglycemic event often develops B. physical dependency on the drug develops over time. C. a heart block is likely to develop. D. status epileptic us may develop

Correct Answer is D

Explanation

A) Hypoglycemic event often develops:
Phenytoin is an anticonvulsant, and while it can affect glucose metabolism, hypoglycemia is not a typical consequence of abruptly stopping the drug. This is not a primary concern when discontinuing phenytoin therapy. Hypoglycemia is more commonly associated with medications like insulin or sulfonylureas, not anticonvulsants like phenytoin.

B) Physical dependency on the drug develops over time:
Phenytoin does not cause physical dependence in the way that some other substances (e.g., alcohol, opioids) can. While the body can become used to a medication over time, and withdrawal symptoms can occur, the risk of physical dependence is not the main reason why phenytoin should not be stopped suddenly.

C) A heart block is likely to develop:
Phenytoin is known to have effects on cardiac conduction, and it can cause heart rhythm disturbances like bradycardia or a prolonged PR interval, especially with toxicity. However, the risk of a heart block developing due to abrupt discontinuation of phenytoin is not the primary concern.

D) Status epilepticus may develop:
The most serious risk of suddenly stopping phenytoin, or any anticonvulsant, is the potential for status epilepticus. Status epilepticus is a medical emergency where seizures occur continuously without recovery in between, which can be life-threatening. Abruptly discontinuing phenytoin can lead to a rebound increase in seizure activity, which can result in status epilepticus.

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Naxlex Comprehensive Predictor Exams

A client in the gynecology clinic asks the nurse, ‘’What are the risk factors for developing cervical cancer?’’ Which statement by the nurse is the best response?

Correct Answer is C

Explanation

A nurse is teaching a client newly diagnosed with a seizure disorder about phenytoin sodium therapy. What information should the nurse stress regarding the client stopping the drug suddenly? The drug should not be stopped abruptly because:

Correct Answer is D

Explanation

The nurse is caring for a client with a permanent biventricular pacemaker. What should the nurse include in the discharge teaching?

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The nurse easily and quickly assesses changes in level of consciousness (eye opening, verbal responses motor response) using which neurological exams?

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