NURSE MED SURGE Medical surgical and HESI. Exam Questions and Answers with Rationale

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NURSE MED SURGE Medical surgical and HESI. Exam Questions and Answers • The nurse is providing home care information to a client who has undergone a skin biopsy. Which information should the nurse ... include in the instructions? 1. Soak the site in warm water three times a day 2. Expect redness and drainage at the biopsy site 3. Expect a significant amount of pain at the biopsy site 4. Keep the dressing dry and in place for at least 8 hours • A client who was exposed to cold for a prolonged period is brought to the emergency department. The nurse, conducting an assessment of the client, notes acute frostbite of the fingers of the left hand. Which action should the nurse take immediately? 1. Placing the client’s fingers in cold water for 15 to 20 minutes 2. Placing the client’s fingers in warm water for 15 to 20 minutes 3. Placing the client’s fingers in warm water for 5 minutes, then debriding any obvious blisters 4. Placing the client’s fingers in cold water for 10 minutes and then warm water for 10 minutes and continuing this pattern for 1 hour The nurse notes documentation in a client’s record that the client has a stage IV pressure ulcer. What does the nurse expect to see during assessment? 1. 2. 3. 4. Subcutaneous tissue may be visible, and undermining and tunneling may or may not be present. In stage IV, full-thickness skin loss is present, with exposure of bone, tendon, or muscle. Sloughing or an eschar may be present, as may undermining and tunneling. • A client has sustained superficial partial-thickness burns of the anterior surfaces of the thighs. On assessment, which of these characteristics would the nurse expect to see? Select all that apply. • • 1. Mild erythema • 2. Blistering and edema • 3. Blackening without edema • 4. Wet, shiny, weeping surface • 5. Red base and broken epidermis • 6. Yellow discoloration with severe edema • Escharotomy is performed on the legs of a client who has sustained circumferential burns. Which parameter does the nurse use to evaluate the effectiveness of the procedure? • • 1. Blood pressure • 2. Apical pulse rate • 3. Body temperature • 4. Dorsalis pedis pulses • RATIONALE • Escharotomy is the primary surgical procedure for the treatment of inadequate tissue perfusion in the presence of a burn injury. In this procedure, an incision is made through the burn eschar to relieve pressure caused by the restricting force of the circumferential burns on the extremity and to improve circulation. To evaluate the effectiveness of the procedure, the nurse checks the pedal pulses. Although the nurse would check the client’s apical pulse rate and blood pressure to determine circulatory status and the client’s temperature as an indicator of possible infection, these measurements would not reveal the effectiveness of the escharotomy. • A nurse is hiking in the woods with some friends when one of the friends sustains a snakebite on the ankle. What action should the nurse take first? • • 1. Immobilizing the affected extremity • 2. Removing jewelry and constricting clothing • 3. Moving the victim to a safe area away from the snake • 4. Covering the victim with available items to keep him warm [Show More]

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