Here are the Questions to NCLEX Preparation Course - Critical Thinking VI (51-60) -->
51) A
- Zidovudine causes bone marrow depression that results to neutropenia. WBC levels should be monitored regularly
52) D
- HIV can be transferred through the colostrum. Therefore, breastfeeding may not be advised.
53) B
- AIDS and HBV infection are both bloodborne infections. Both patients do not have contagious diseases.
Client with other forms of infection especially airborne ones and those with lowered resistance to infection should not be roomed-in with the client with AIDS.
54) A
- the client who had multiple body piercing has the highest risk to develop HIV because of risk of exposure to contaminated needles.
55) C
- both clients have infections; however, the infections are not contagious, so they could be roomed-in.
56) D
- a burn is a tissue damage resulting from excessive heat, electricity, caustic chemicals or radiation.
The method for assessing the degree of burn injury according to source, depth, severity, and extent:
DEPTH - measures according to degree or thickness of injured area. When assessing depth, see the appearance of the burn and the sensitivity of the area to pain as major criteria.
- Partial Thickness or first degree burn - involved the epidermal layer of the skin. The skin appears pinkish or red, blanches with pressure and is painful but usually without large blisters. Mild sunburn is an example of this type of burn. It heals without treatment within 3-5 days
- Moderate to deep partial thickness burn or Second degree burn - involves the dermal layer of the skin with the skin appearing pinkish, reddish, or whitish with blisters. Burn from hot steam is an example. This type of burn heals slowly and may require weeks (21-28 days) before the skin can regenerate completely.
- Full thickness burns or Third degree burn - involves the entire layers of the skin, blood vessels and subcutaneous tissue. Nerves, hair follicles and sweat glands are also destroyed. It is not painful because nerves have been destroyed. This type of burn injury has a waxy and leathery appearance. Burn will not heal spontaneously because skin cannot regenerate due to destruction of the epithelial layer and grafting is needed to regain normal skin look.
- Rule of Nines in adults
- Lund and Browder method can be used in both children and adults
- Minor
- less than 15% TBSA burn in adults less than 40 years old
- less than 10% TBSA burn in adults more than 40 years old
- less than 10% TBSA burn in children less than 10 years old with:
- less than 2% TBSA full thickness burn and no cosmetic or functional risk to face, eyes, ears, hands, feet or perineum.
- 15-25% TBSA burn in adults less than 40 years old
- 10-20% TBSA burn in adults more than 40 years old
- 10-20% TBSA burn in children less than 10 years old with
- less than 10% TBSA full thickness burn and no cosmetic or functional risk to face, eyes, ears, hands, feet or perineum.
- 25% TBSA burn in adults less than 40 years old
- 20% TBSA burn in adults more than 40 years old
- 20% TBSA burn in adults less than 10 years old or
- burns face, eyes, ears, hands, feet, or perineum that will result to cosmetic or functional disability or
- high voltage electrical burn injury or
- all burns injuries with concomitant inhalation injury or major trauma
- thermal burns - are caused by flame, flash (explosion) and scald injuries
- Electrical burns -are caused by lightning and electrical current
- chemical burns - are due to ingestion or contact with caustic chemicals or corrosive substances such as muriatic acid
- inhalation injury is caused by inhalation of noxious chemical or heat.
- The percentage designated for each burned part of the body using the rule of nines:
- Head and Neck: 9%
- right upper extremity: 9%
- left upper extremity: 9%
- anterior trunk 18%
- posterior trunk 18%
- right lower extremity: 18%
- left lower extremity: 18%
- perineum: 1%
- The first priority in burn accidents is to stop the burning process which includes:
Smothering the Flame
Stop burning by removing person from source of burn and extinguishing burning
- for a flame burn, drop person to the ground and log roll the person to extinguish the flames
- use lots of water to douse the flames and cool the wound quickly. Remove any jewelry from the burned area as metal retains heat and may continue burning. Do not remove adherent clothing. Do not immense a large wound in water
- For chemical burn, brush off dry chemicals and immediately cleanse with a lot of running clean, cool water. Remove clothing and again rinse the injured area with clean coll water for 15 to 20 minutes to remove all chemicals. Never neutralize the chemical.
- For electrical burns, turn off the source of electricity immediately or separate the person from electrical current by using nonconductive equipment. Assess cardiopulmonary function and start CPR immediately.
Do not apply ointments or creams to burn at this time
Transport the person as quickly as possible to the nearest emergency room. If treatment is delayed for more than one hour, IV fluid replacement may be started if qualified people are available. Usually nothing is given by mouth since nausea and vomiting may occur as a result of paralytic ileus secondary to stress of injury. If medical attention will be delayed for hours and the person can tolerate oral fluids, give a mixture of water, salt and sodium bicarbonate to replace fluid and salt and combat acidosis.
59) A
- normal urine output should be 30 ml/hr or 100/4hrs
Factors affecting normal urinary elimination:
- fluid intake - most important factor in determining amount of urine; more intake more urine formation
- loss of body fluid - increase loss of body fluids causes the kidney to reabsorb more water resulting in decreased volume of urine
- nutrition - dietary intake affects urination. Caffeine and alcohol has diuretic effect that increases urine volume. Food with high water content can increase urine output
- body position - position for voiding effects urinary output. A person voids well when he or she is in a comfortable voiding position
- psychological factors - several factors can induce or prevent a person from voiding. Privacy and running water may encourage voiding. Cold bedpan and stress may prevent voiding because of contraction of muscles involved in the normal voiding process.
- cradle bed should be used to support the sheets that cover the patient so that it will not get in contact with the wounds of the patient. This is to allow them to dry, reduce pain and prevent infection.
Stryker Frame facilitates changing of position by use of two mattress sections. The patient lies on the bottom mattress while the top mattress is secured and the entire frame is rotated manually in turning the patient.
Circulo-electric bed is a rotating frame that is electrically operated to turn the patient from head to toe.
Dressings not bandages are used on burned wounds.
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