Podcast
Questions and Answers
Which nursing intervention should the nurse include in the care plan?
Which nursing intervention should the nurse include in the care plan?
Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?
Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?
Which client assessment data are priority for the post-anesthesia care nurse?
Which client assessment data are priority for the post-anesthesia care nurse?
The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement?
The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement?
Signup and view all the answers
The postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?
The postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?
Signup and view all the answers
Which client problem would the nurse include in the plan of care for an elderly postoperative client who became confused during the previous shift?
Which client problem would the nurse include in the plan of care for an elderly postoperative client who became confused during the previous shift?
Signup and view all the answers
The client one day postoperative develops an elevated temperature. Which intervention would have priority for the client?
The client one day postoperative develops an elevated temperature. Which intervention would have priority for the client?
Signup and view all the answers
Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?
Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?
Signup and view all the answers
Which interventions should the nurse implement for a client who is two (2) hours postoperative with noted vital signs: T 102.6°F, P 132, R 26, BP 92/46?
Which interventions should the nurse implement for a client who is two (2) hours postoperative with noted vital signs: T 102.6°F, P 132, R 26, BP 92/46?
Signup and view all the answers
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. Which depth of burn should the nurse document?
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. Which depth of burn should the nurse document?
Signup and view all the answers
The client with full-thickness burns to 40% of the body is being transferred to a burn center. Which measure should be instituted before the transfer?
The client with full-thickness burns to 40% of the body is being transferred to a burn center. Which measure should be instituted before the transfer?
Signup and view all the answers
After establishing a patent airway in a client with full-thickness burns to 65% of the body, including the chest area, what is the priority collaborative intervention?
After establishing a patent airway in a client with full-thickness burns to 65% of the body, including the chest area, what is the priority collaborative intervention?
Signup and view all the answers
While applying mafenide acetate (Sulfamylon) to a client's lower extremity burn, which assessment data would require immediate attention by the nurse?
While applying mafenide acetate (Sulfamylon) to a client's lower extremity burn, which assessment data would require immediate attention by the nurse?
Signup and view all the answers
What is a xenograft?
What is a xenograft?
Signup and view all the answers
Which client problem has priority for a client with severe full-thickness and deep partial-thickness burns over half the body?
Which client problem has priority for a client with severe full-thickness and deep partial-thickness burns over half the body?
Signup and view all the answers
Which intervention would be appropriate for the nursing diagnosis 'impaired skin related to open burn wounds'?
Which intervention would be appropriate for the nursing diagnosis 'impaired skin related to open burn wounds'?
Signup and view all the answers
Which nursing intervention should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body?
Which nursing intervention should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body?
Signup and view all the answers
Which assessment data would warrant notifying the health-care provider for a client with deep partial-thickness and full-thickness burns to the chest area?
Which assessment data would warrant notifying the health-care provider for a client with deep partial-thickness and full-thickness burns to the chest area?
Signup and view all the answers
Which intervention should the nurse implement for a client with full-thickness and partial-thickness burns to more than 30% of the body concerning nutritional status?
Which intervention should the nurse implement for a client with full-thickness and partial-thickness burns to more than 30% of the body concerning nutritional status?
Signup and view all the answers
Which information should the nurse provide to a client who sustained a hot grease burn to the right hand?
Which information should the nurse provide to a client who sustained a hot grease burn to the right hand?
Signup and view all the answers
Which strategies should the nurse identify to promote the client's mental health upon discharge after being in the burn unit for six weeks?
Which strategies should the nurse identify to promote the client's mental health upon discharge after being in the burn unit for six weeks?
Signup and view all the answers
Which intervention should the nurse implement when discussing health promotion activities for a client with a German heritage who leads a sedentary lifestyle?
Which intervention should the nurse implement when discussing health promotion activities for a client with a German heritage who leads a sedentary lifestyle?
Signup and view all the answers
The elderly female client of Mexican heritage is upset and tells the nurse the unlicensed assistive personnel (AP) complimented her grandchild's hair. Which intervention should the nurse implement?
The elderly female client of Mexican heritage is upset and tells the nurse the unlicensed assistive personnel (AP) complimented her grandchild's hair. Which intervention should the nurse implement?
Signup and view all the answers
Which intervention should the nurse implement for the home health care visit to an elderly African American female client who talks loudly?
Which intervention should the nurse implement for the home health care visit to an elderly African American female client who talks loudly?
Signup and view all the answers
In visiting a 42-year-old male client with terminal cancer, which behavior would best promote a therapeutic nurse/client relationship?
In visiting a 42-year-old male client with terminal cancer, which behavior would best promote a therapeutic nurse/client relationship?
Signup and view all the answers
When interviewing the client of Hindu heritage, which information should the nurse obtain to plan culturally sensitive care?
When interviewing the client of Hindu heritage, which information should the nurse obtain to plan culturally sensitive care?
Signup and view all the answers
Which rationale should the nurse give the AP for allowing the client to continue to wear the amulet?
Which rationale should the nurse give the AP for allowing the client to continue to wear the amulet?
Signup and view all the answers
After evaluating the meal tray of a Jewish client, the nurse notices the client ate none of the meal. Which intervention should the nurse implement first?
After evaluating the meal tray of a Jewish client, the nurse notices the client ate none of the meal. Which intervention should the nurse implement first?
Signup and view all the answers
Which complementary therapy should the nurse suggest to assist the client's weight-loss program?
Which complementary therapy should the nurse suggest to assist the client's weight-loss program?
Signup and view all the answers
When incorporating complementary therapies in a long-term care facility, which information should the nurse consider when matching the clients with the therapy? (Select all that apply)
When incorporating complementary therapies in a long-term care facility, which information should the nurse consider when matching the clients with the therapy? (Select all that apply)
Signup and view all the answers
Which form of complementary therapy should the nurse encourage as a relaxation technique for the anxious elderly client admitted for surgery?
Which form of complementary therapy should the nurse encourage as a relaxation technique for the anxious elderly client admitted for surgery?
Signup and view all the answers
What should the nurse include in the client's pain management plan for a client with a history of drug abuse?
What should the nurse include in the client's pain management plan for a client with a history of drug abuse?
Signup and view all the answers
Which intervention should the circulating nurse implement for the preoperative elderly client who is anxious and diaphoretic?
Which intervention should the circulating nurse implement for the preoperative elderly client who is anxious and diaphoretic?
Signup and view all the answers
Which statement best supports the nurse allowing the male Navajo client to wear the pouch filled with objects around his neck?
Which statement best supports the nurse allowing the male Navajo client to wear the pouch filled with objects around his neck?
Signup and view all the answers
Which statement explains the role of the curandero in Mexican culture?
Which statement explains the role of the curandero in Mexican culture?
Signup and view all the answers
The home health nurse is visiting a Jewish client who has a small container on the doorpost of the house. What term best describes this container?
The home health nurse is visiting a Jewish client who has a small container on the doorpost of the house. What term best describes this container?
Signup and view all the answers
Which intervention should the nurse implement for a client who requests to keep his religious medal on during surgery?
Which intervention should the nurse implement for a client who requests to keep his religious medal on during surgery?
Signup and view all the answers
Which client would not be able to consent legally to surgery?
Which client would not be able to consent legally to surgery?
Signup and view all the answers
Which intervention should the nurse implement first when preparing a client for surgery?
Which intervention should the nurse implement first when preparing a client for surgery?
Signup and view all the answers
The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after (3) tap water enemas. Which intervention should the nurse implement first?
The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after (3) tap water enemas. Which intervention should the nurse implement first?
Signup and view all the answers
Which interventions should the nurse include in the care plan for a male client undergoing abdominal surgery? (Select all that apply)
Which interventions should the nurse include in the care plan for a male client undergoing abdominal surgery? (Select all that apply)
Signup and view all the answers
Which behavior indicates the need for further preoperative teaching for a client scheduled for total hip replacement?
Which behavior indicates the need for further preoperative teaching for a client scheduled for total hip replacement?
Signup and view all the answers
Which intervention should the nurse implement first when a client states they are allergic to codeine?
Which intervention should the nurse implement first when a client states they are allergic to codeine?
Signup and view all the answers
Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?
Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?
Signup and view all the answers
Which information should the nurse report to the anesthesiologist for a surgical client? (Select all that apply)
Which information should the nurse report to the anesthesiologist for a surgical client? (Select all that apply)
Signup and view all the answers
Which activities are the circulating nurse's responsibilities in the operating room?
Which activities are the circulating nurse's responsibilities in the operating room?
Signup and view all the answers
What should the nurse do when the surgical scrub technician removes a sponge from the edge of the sterile field with a clamp?
What should the nurse do when the surgical scrub technician removes a sponge from the edge of the sterile field with a clamp?
Signup and view all the answers
When the circulating nurse and the scrub technician find a discrepancy in the sponge count, what should the circulating nurse take first?
When the circulating nurse and the scrub technician find a discrepancy in the sponge count, what should the circulating nurse take first?
Signup and view all the answers
Which violation of surgical asepsis would require immediate intervention by the circulating nurse?
Which violation of surgical asepsis would require immediate intervention by the circulating nurse?
Signup and view all the answers
Which nursing intervention should the nurse implement for the client who is identified as 'risk for injury related to positioning' in the operating room?
Which nursing intervention should the nurse implement for the client who is identified as 'risk for injury related to positioning' in the operating room?
Signup and view all the answers
Which client has the greatest potential for nerve damage during surgery?
Which client has the greatest potential for nerve damage during surgery?
Signup and view all the answers
Which situation demonstrates the circulating nurse acting as the client's advocate?
Which situation demonstrates the circulating nurse acting as the client's advocate?
Signup and view all the answers
Which statement is the expected outcome when planning care for an intraoperative client?
Which statement is the expected outcome when planning care for an intraoperative client?
Signup and view all the answers
Which nursing intervention has the highest priority when preparing the client for a surgical procedure?
Which nursing intervention has the highest priority when preparing the client for a surgical procedure?
Signup and view all the answers
Which case should the nursing manager assign to the inexperienced nurse?
Which case should the nursing manager assign to the inexperienced nurse?
Signup and view all the answers
The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement?
The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement?
Signup and view all the answers
Which intervention has the highest priority when planning the care of a surgical client having conscious sedation?
Which intervention has the highest priority when planning the care of a surgical client having conscious sedation?
Signup and view all the answers
The PACU nurse is receiving the client from the OR. What should the nurse assess first?
The PACU nurse is receiving the client from the OR. What should the nurse assess first?
Signup and view all the answers
Which intervention should the nurse implement first?
Which intervention should the nurse implement first?
Signup and view all the answers
Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
Signup and view all the answers
After transferring the client from the PACU to the surgical unit, which intervention should the nurse implement first?
After transferring the client from the PACU to the surgical unit, which intervention should the nurse implement first?
Signup and view all the answers
Which client problem should the nurse add to the plan of care for a client who received Narcan?
Which client problem should the nurse add to the plan of care for a client who received Narcan?
Signup and view all the answers
Which interventions should the nurse implement for the 26-year-old male client in the PACU? Select all that apply.
Which interventions should the nurse implement for the 26-year-old male client in the PACU? Select all that apply.
Signup and view all the answers
Which data indicate the nursing care has been effective for the client who is one day postoperative surgery?
Which data indicate the nursing care has been effective for the client who is one day postoperative surgery?
Signup and view all the answers
Which task can the nurse delegate to the unlicensed nursing assistant?
Which task can the nurse delegate to the unlicensed nursing assistant?
Signup and view all the answers
Which postoperative client is the most appropriate assignment for the graduate nurse?
Which postoperative client is the most appropriate assignment for the graduate nurse?
Signup and view all the answers
Which statement would be an expected outcome for the postoperative client who had general anesthesia?
Which statement would be an expected outcome for the postoperative client who had general anesthesia?
Signup and view all the answers
When transferring the postoperative client from the PACU to the surgical floor, which action should the nurse implement first?
When transferring the postoperative client from the PACU to the surgical floor, which action should the nurse implement first?
Signup and view all the answers
What is the priority client problem for someone who is one day postoperative?
What is the priority client problem for someone who is one day postoperative?
Signup and view all the answers
What intervention would be most appropriate for a first-day postoperative client's vital signs of T 100.8F, P 80, R 24, and B/P 148/80?
What intervention would be most appropriate for a first-day postoperative client's vital signs of T 100.8F, P 80, R 24, and B/P 148/80?
Signup and view all the answers
Which intervention should the nurse implement first for a client complaining of left shoulder pain?
Which intervention should the nurse implement first for a client complaining of left shoulder pain?
Signup and view all the answers
Which intervention should the nurse implement for a client in acute pain as a result of surgery?
Which intervention should the nurse implement for a client in acute pain as a result of surgery?
Signup and view all the answers
Which situation exemplifies the nurse fulfilling the role of client advocate?
Which situation exemplifies the nurse fulfilling the role of client advocate?
Signup and view all the answers
Which statement would indicate an expected outcome for a client experiencing acute pain?
Which statement would indicate an expected outcome for a client experiencing acute pain?
Signup and view all the answers
Which intervention has the highest priority when administering pain medication to a client experiencing acute pain?
Which intervention has the highest priority when administering pain medication to a client experiencing acute pain?
Signup and view all the answers
Which intervention can the nurse delegate to the unlicensed nursing assistant when caring for a client experiencing acute pain?
Which intervention can the nurse delegate to the unlicensed nursing assistant when caring for a client experiencing acute pain?
Signup and view all the answers
Which interventions should the nurse implement to provide for client safety when administering an opioid narcotic? Select all that apply.
Which interventions should the nurse implement to provide for client safety when administering an opioid narcotic? Select all that apply.
Signup and view all the answers
Which technique would be most appropriate for the nurse to implement when assessing a four-year-old client for acute pain?
Which technique would be most appropriate for the nurse to implement when assessing a four-year-old client for acute pain?
Signup and view all the answers
Which nursing intervention would be a priority for the client experiencing acute pain?
Which nursing intervention would be a priority for the client experiencing acute pain?
Signup and view all the answers
While interviewing a 75-year-old client admitted with acute pain, which question would take priority when assisting with pain management?
While interviewing a 75-year-old client admitted with acute pain, which question would take priority when assisting with pain management?
Signup and view all the answers
What should the nurse implement after discovering that the client has used only a small amount of medication during the shift with the PCA pump?
What should the nurse implement after discovering that the client has used only a small amount of medication during the shift with the PCA pump?
Signup and view all the answers
Which problem would be most appropriate for the nurse to identify for a client experiencing acute pain?
Which problem would be most appropriate for the nurse to identify for a client experiencing acute pain?
Signup and view all the answers
Which client would the nurse identify as having the highest risk for developing postoperative complications?
Which client would the nurse identify as having the highest risk for developing postoperative complications?
Signup and view all the answers
Which information should the nurse report to the surgeon during the preoperative checklist?
Which information should the nurse report to the surgeon during the preoperative checklist?
Signup and view all the answers
What explains the nurse's responsibility when obtaining informed consent for the client undergoing surgery?
What explains the nurse's responsibility when obtaining informed consent for the client undergoing surgery?
Signup and view all the answers
Which client outcome should the nurse identify for the preoperative client?
Which client outcome should the nurse identify for the preoperative client?
Signup and view all the answers
Which problem would be appropriate for the nurse to identify for a preoperative client having an open reduction and internal fixation of the right ankle?
Which problem would be appropriate for the nurse to identify for a preoperative client having an open reduction and internal fixation of the right ankle?
Signup and view all the answers
Which task would be most appropriate to delegate to unlicensed assistive personnel?
Which task would be most appropriate to delegate to unlicensed assistive personnel?
Signup and view all the answers
Which action indicates that preoperative teaching has been effective?
Which action indicates that preoperative teaching has been effective?
Signup and view all the answers
Which intervention has priority for the nurse in the surgical holding area?
Which intervention has priority for the nurse in the surgical holding area?
Signup and view all the answers
What should the nurse say when the client in the surgical holding area expresses fear about the surgery?
What should the nurse say when the client in the surgical holding area expresses fear about the surgery?
Signup and view all the answers
What should the nurse do if overhearing a UAP discussing a problem during one of the surgeries?
What should the nurse do if overhearing a UAP discussing a problem during one of the surgeries?
Signup and view all the answers
Which laboratory value should the nurse report to the health care provider immediately during the preoperative checklist?
Which laboratory value should the nurse report to the health care provider immediately during the preoperative checklist?
Signup and view all the answers
Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
Signup and view all the answers
What nursing intervention should be implemented to decrease a complication from the lithotomy position during surgery?
What nursing intervention should be implemented to decrease a complication from the lithotomy position during surgery?
Signup and view all the answers
What should the circulating nurse do upon observing the surgeon tossing a bloody gauze sponge onto the sterile field?
What should the circulating nurse do upon observing the surgeon tossing a bloody gauze sponge onto the sterile field?
Signup and view all the answers
What should the circulating nurse do upon noting a discrepancy in the needle count?
What should the circulating nurse do upon noting a discrepancy in the needle count?
Signup and view all the answers
Which interventions should the nurse implement if the client identifies the left arm as the surgical site but the permit designates the right arm? Select all that apply.
Which interventions should the nurse implement if the client identifies the left arm as the surgical site but the permit designates the right arm? Select all that apply.
Signup and view all the answers
Which assessment data would warrant immediate intervention for a client received from the post-anesthesia care unit?
Which assessment data would warrant immediate intervention for a client received from the post-anesthesia care unit?
Signup and view all the answers
What should the nurse be aware of after a client received naloxone (Narcan), an opioid antagonist, in the post-anesthesia care unit?
What should the nurse be aware of after a client received naloxone (Narcan), an opioid antagonist, in the post-anesthesia care unit?
Signup and view all the answers
Study Notes
Health Promotion and Cultural Sensitivity
- Promote exercise routines for clients with sedentary lifestyles, considering their heritage.
- Address cultural sensitivities, such as the "evil eye" belief in certain communities, when handling personal compliments.
- Understand that loud talking may not indicate anger; cultural factors and communication styles vary among individuals.
Therapeutic Communication and Family Dynamics
- Initial communication with clients should consider addressing the eldest family member first, especially in culturally diverse families.
- Engaging with clients about their cultural practices and preferences (e.g., use of ayurveda) enhances culturally sensitive care.
Complementary and Alternative Therapies
- Hypnotherapy can assist in weight-loss programs by offering alternative approaches.
- Complementary therapies, such as deep breathing and music therapy, may be integrated for anxiety management pre-surgery.
- Encourage discussions on pain management that includes both medications and complementary therapies for clients with drug abuse histories.
Pre- and Postoperative Care
- Performing a preoperative checklist is essential to ensure all aspects of care are addressed before surgery.
- Understanding patients' health status is critical; for instance, notify the surgeon if a client has abnormal lab values like low potassium levels.
- During postoperative care, monitor for respiratory complications, especially following spinal anesthesia.
Patient Consent and Legal Considerations
- Legal competence for surgical consent varies; assess factors such as age and mental orientation.
- Gather detailed allergy histories, focusing on specific reactions to medications like codeine, to ensure safe practices.
Safety Protocols in Surgery
- The responsibilities of the circulating nurse include patient safety and maintaining sterile conditions.
- Interventions for patients at risk of injury during surgery involve taking precautions like padding extremities.
Recognizing and Responding to Emergencies
- Detect vital sign irregularities such as tachycardia and hypotension, which may indicate medical emergencies.
- Quick actions, like elevating the head after transfer from PACU if abnormal signs are noted, are crucial for patient stability.
Cultural Objects and Practices
- Respect and understand the significance of cultural items such as amulets and pouches worn by clients, ensuring they are not removed without understanding their importance.
Dietary Considerations
- Assess dietary restrictions for clients, such as ensuring kosher meals for Jewish patients, to promote adequate nutritional intake.
Emotional and Psychological Support
- Provide emotional support through familiar items, like religious medals, during surgical procedures to alleviate anxiety.
- Be aware of postoperative symptoms indicating complications, including respiratory distress or changes in blood pressure.### Postoperative Nursing Care
- Temperature Monitoring: A postoperative client with T 99.0°F, P 98, R 20, and BP 100/60 indicates effective recovery after surgery.
- Vital Signs Assessment: First action upon transfer from PACU to surgical floor is to assess the client's vital signs.
- Delegation: Unlicensed Nursing Assistants (UAPs) can take vital signs every four hours but cannot check surgical sites or administer medications.
Postoperative Complications
- Potential Hemorrhaging: Recognized as priority complication for clients one day postoperative.
- Monitoring for Infection: Vital signs and drainage from surgical sites must be regularly monitored to prevent infection.
Pain Management
- Acute Pain Interventions: Administer pain medication as soon as the schedule allows; always assess patient's verbal and nonverbal cues for pain.
- Client Education: Clients should understand to report pain adequately and use prescribed pain management techniques (e.g., PCA).
- Nurse Advocacy: Nurses should contact health care providers when pain relief is not achieved.
Preoperative Considerations
- Informed Consent: Nurses must ensure clients voluntarily consent to surgery without coercion or misunderstanding.
- Assessment of Risks: Report any significant findings (e.g. herbal supplement use) to the surgeon before surgery.
Surgical Preparedness
- Preoperative Checklist: Must confirm details such as site marking and surgical permits before procedures.
- Patient Teaching: Effective teaching includes demonstrating the use of an incentive spirometer and discussing postoperative care.
Post-Anesthesia Care Unit (PACU) Focus
- Vital Signs Priority: Continuous monitoring of vital signs is essential for identifying complications after surgery.
- Respiratory Monitoring: After administering naloxone for opioid reversal, monitor respiratory rate frequently (every 15 to 30 minutes).
Emergency Situations
- Postoperative Complications: Immediate intervention is required for clients with abnormal vital signs, such as vomiting, altered consciousness, or severe pain.
Discharge Readiness
- Effective Discharge Education: Clients should verbalize understanding of medication regimes, particularly the importance of completing antibiotics.
Special Considerations in Surgical Patients
- Elderly Clients: Increased vigilance for confusion and fall risks in older adults postoperatively; consider "risk for injury" in care plans.
- Pain Assessment Techniques: Use age-appropriate methods for pain evaluation, such as the pain scale for children or non-verbal cues for elderly clients.
Acknowledging Non-Compliance
- Medication Adherence: Emphasize the necessity of completing prescribed medications to prevent complications; clients should not assume they will have no further pain control needs post-surgery.
Potential Complications of Positioning
- Lithotomy Positioning: Lowering one leg at a time can help decrease complications associated with prolonged surgical positioning, such as circulatory issues.
Nursing Responsibilities During Surgery
- Surgical Counts: Ensure all instruments and supplies' counts are accurate and report any discrepancies immediately to maintain patient safety.### Burn Classification and Assessment
- Blistered, mottled red skin with edema suggests deep partial thickness burn.
- Full-thickness burns covering significant areas (e.g., 40% body including legs) necessitate interventions before transfer to a burn center, ensuring adequate peripheral circulation.
- In cases of full-thickness burns (e.g., 65% body), immediate emphasis on replacing fluids and electrolytes is prioritized after airway stabilization.
Medication Administration and Patient Monitoring
- Mafenide acetate (Sulfamylon) may cause pain upon application; however, abnormal ABG results (e.g., pH 7.34, low HCO3) require immediate nursing intervention.
- Knowledge of xenografts is essential; they involve grafts sourced from animals, often pigs.
Nursing Priorities and Care Plans
- High risk for infection is the primary concern in burn patients with extensive injuries (e.g., full-thickness and deep partial-thickness over 50% body).
- Daily wound cleansing is vital in managing open burn wounds and preventing infection.
Infection Control Measures
- Strict hygiene practices are crucial; thorough hand hygiene, sterile gloves for wound care, and wearing gowns/masks during procedures are essential.
- Administer prescribed antibiotics to combat infection risk in severe burn cases.
Patient Assessment and Health Provider Notification
- Urinary output of 50 mL in 2 hours raises concern and should prompt healthcare provider notification.
- Signs of severe pain and vital sign changes (e.g., fever) also warrant close monitoring.
Nutritional Support
- Family involvement in nutritional care is beneficial; encouraging familiarity and preference in food can aid recovery.
- Weight monitoring should be consistent for accurate assessment of nutritional status.
First Aid and Initial Treatment
- For hot grease burns, immediate action involves placing the affected area in cool water rather than applying ice packs, which can cause further damage.
Mental Health Strategies Post-Discharge
- Encouraging realistic expectations regarding lifestyle changes is important for mental well-being post-discharge.
- Promoting social interaction and community engagement is preferable to isolation.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge on health promotion interventions for clients with diverse backgrounds in this Med Surg Success Q & A quiz. This quiz focuses on implementing effective strategies for clients, especially those from a German heritage living a sedentary lifestyle.
