Hesi Milestone 1
VERIFIED SOLUTION
WITH CORRECT
ANSWERS
list 4 categories of burns - ANSWER Thermal, radiation, chemical, electrical
Burn depth is a measure of severity. Describe the characteristics of superficial partial-
thickness, deep partial-thickness, and full-thickness burns. - ANSWER -superficial
partial thickness, first degree: pink to red skin (sunburn), slight edema and pain relieved
by cooling.
-deep partial thickness, second degree: destruction of epidermis and upper layers of
dermis, white or red very edematous, sensitive to touch and cold air, hair does not pull
out easily.
-full thickness, third degree: total destruction of dermis and epidermis, reddened areas
do not blanch with pressure, not painful, inelastic, waxy white skin to brown, leathery
eschar.
describe fluid management in the emergent phase, acute phase, and rehabilitation
phase of the burned client - ANSWER -Stage 1 (emergency phase): replacement of
fluids is titrated to urine output.
-Stage 2 (acute phase): patent infusion site is maintained in case supplemental IV fluids
are needed, saline lock is helpful, colloids may be used
-Stage 3 (rehabilitation phase): no extra fluids are needed, but high protein drinks are
recommended.
, Describe pain management of the burned client. - ANSWER Administer pain
medication, especially before dressing wound. Teach distraction and relaxation
techniques. Teach use of guided imagery.
Outline admission care of the burned client. - ANSWER Provide a patent airway
because intubation may be necessary. Determine baseline data. Initiate fluid and
electrolyte therapy. Administer pain medication. Determine depth and extent of burn.
Administer tetanus toxoid. Insert NG tube.
nutritional status is a major concern when caring for a burned client. list three specific
dietary interventions used with burned clients. - ANSWER high calorie, high protein,
high carb diet, medications with juice or milk, no free water, tube feeding at night.
Maintain accurate daily calorie counts, weigh client daily
describe the method of extinguishing each of the following burns, thermal, chemical and
electrical - ANSWER -Thermal: remove clothing, immerse in tepid water
-Chemical: flush with water or saline
-Electrical: separate client from electrical source
list four signs of inhalation burn - ANSWER singed nasal hairs, circumoral burns,
sooty/bloody sputum, hoarseness, pulmonary signs including asymmetrical of
respirations, rales or wheezing
Why is the burned client allowed no "free" water? - ANSWER Water may interfere with
electrolyte balance. Client needs to ingest food products with highest biologic value
Describe an autograft - ANSWER Use of clients own skin for grafting
what are the indications for a hysterectomy in a client who has fibromas - ANSWER
severe mennorhagia leading to anemia, severe dysmenorrhea requiring narcotic
analgesics, severe uterine enlargement causing pressure on other organs, severe back
and pelvic pain
List the symptoms and conditions associated with a cystocele. - ANSWER symptoms
include incontinence or stress incontinence, urinary retention and recurrent bladder
infections. Conditions associated with cystocele include multiparty, trauma in childbirth
and aging
what are the most important nursing interventions for the post op client who has had a
hysterectomy with an A&P repair - ANSWER avoid taking rectal temps and rectal
manipulation, manage pain and encourage early ambulation
describe the priority nursing care for a client who has radiation implants - ANSWER do
not permit pregnant visitors or pregnant care takers in room. Discourage visits by small
children. Confine client to room. Nurse must wear radiation badge, nurse limits time in
room and keep supplies and equipment within clients reach
VERIFIED SOLUTION
WITH CORRECT
ANSWERS
list 4 categories of burns - ANSWER Thermal, radiation, chemical, electrical
Burn depth is a measure of severity. Describe the characteristics of superficial partial-
thickness, deep partial-thickness, and full-thickness burns. - ANSWER -superficial
partial thickness, first degree: pink to red skin (sunburn), slight edema and pain relieved
by cooling.
-deep partial thickness, second degree: destruction of epidermis and upper layers of
dermis, white or red very edematous, sensitive to touch and cold air, hair does not pull
out easily.
-full thickness, third degree: total destruction of dermis and epidermis, reddened areas
do not blanch with pressure, not painful, inelastic, waxy white skin to brown, leathery
eschar.
describe fluid management in the emergent phase, acute phase, and rehabilitation
phase of the burned client - ANSWER -Stage 1 (emergency phase): replacement of
fluids is titrated to urine output.
-Stage 2 (acute phase): patent infusion site is maintained in case supplemental IV fluids
are needed, saline lock is helpful, colloids may be used
-Stage 3 (rehabilitation phase): no extra fluids are needed, but high protein drinks are
recommended.
, Describe pain management of the burned client. - ANSWER Administer pain
medication, especially before dressing wound. Teach distraction and relaxation
techniques. Teach use of guided imagery.
Outline admission care of the burned client. - ANSWER Provide a patent airway
because intubation may be necessary. Determine baseline data. Initiate fluid and
electrolyte therapy. Administer pain medication. Determine depth and extent of burn.
Administer tetanus toxoid. Insert NG tube.
nutritional status is a major concern when caring for a burned client. list three specific
dietary interventions used with burned clients. - ANSWER high calorie, high protein,
high carb diet, medications with juice or milk, no free water, tube feeding at night.
Maintain accurate daily calorie counts, weigh client daily
describe the method of extinguishing each of the following burns, thermal, chemical and
electrical - ANSWER -Thermal: remove clothing, immerse in tepid water
-Chemical: flush with water or saline
-Electrical: separate client from electrical source
list four signs of inhalation burn - ANSWER singed nasal hairs, circumoral burns,
sooty/bloody sputum, hoarseness, pulmonary signs including asymmetrical of
respirations, rales or wheezing
Why is the burned client allowed no "free" water? - ANSWER Water may interfere with
electrolyte balance. Client needs to ingest food products with highest biologic value
Describe an autograft - ANSWER Use of clients own skin for grafting
what are the indications for a hysterectomy in a client who has fibromas - ANSWER
severe mennorhagia leading to anemia, severe dysmenorrhea requiring narcotic
analgesics, severe uterine enlargement causing pressure on other organs, severe back
and pelvic pain
List the symptoms and conditions associated with a cystocele. - ANSWER symptoms
include incontinence or stress incontinence, urinary retention and recurrent bladder
infections. Conditions associated with cystocele include multiparty, trauma in childbirth
and aging
what are the most important nursing interventions for the post op client who has had a
hysterectomy with an A&P repair - ANSWER avoid taking rectal temps and rectal
manipulation, manage pain and encourage early ambulation
describe the priority nursing care for a client who has radiation implants - ANSWER do
not permit pregnant visitors or pregnant care takers in room. Discourage visits by small
children. Confine client to room. Nurse must wear radiation badge, nurse limits time in
room and keep supplies and equipment within clients reach
