Burns/disaster nur 213 exam#5

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A. Painful red and white wounds B. Painless, brownish yellow eschar C. Painful reddened blisters D. Painless black skin with eschar

A. Painful red and white woundsA painful red and white wound bed characterizes deep partial-thickness burns; blisters are rare. Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.

the nurse is conducting a primary survey during an emergency assessment. which is the priority nursing action related to breathing in response to this assessment a. having suction available b. assess pupil size and reactivity c. immobilizing any obvious deformities d. obtaining blood samples for type and crossmatch

a

the nurse is conducting a secondary survey as part of the emergency assessment. which is the priority nursing action during the health hx portion of the assessment a. determining drug allergies b. noting the general appearance c. examining for neck stiffness d. auscultating for heart and lung sounds

a

which type of event can often be handles by an individual hospital disaster plan with out collaboration with other systems a. a motor vehicle accident involving five cars b. a tornado destroying 50 homes and businesses c. an act of terrorism injuring and kills hundreds of people d. a hurricane causing flooding, displacing thousands of people

a A multi-casualty event, such as a motor vehicle accident involving five cars, is an event that can often be handled with the implementation of an individual hospital disaster plan without collaboration with other systems.

When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? A. "Every bedroom should have a separate smoke detector." B. "Every room in the house should have a smoke detector." C. "If you have a smoke detector, you don't need a carbon monoxide detector." D. "The kitchen and the bedrooms are the only rooms that need smoke detectors."

a When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors?A. "Every bedroom should have a separate smoke detector."B. "Every room in the house should have a smoke detector."C. "If you have a smoke detector, you don't need a carbon monoxide detector."D. "The kitchen and the bedrooms are the only rooms that need smoke detectors."

which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack a. atropine b. dopamine c. epinephrine d. norepinephrine

a atropine is the antidote for nerve agent poisoning in the disaster plan for a terrorist attack

a patient recovering from 25 % total body surface area burns has a low grade fever. what should the nurse do to reduce this patients risk of developing an infection a. follow contact precautions b. implement protective isolation c. use sterile technique for all dressing changes d. administer prophylactic antibiotics as ordered

a cross contamination among burn patients is common and as a result isolation guidelines are widespread practices among burn centers. contact precautions may be used when entering all patient rooms

what is the best method to prevent autocontamination for a client with burns a. change gloves when handling wounds on different areas of the body b. ensure that the client is in isolation therapy c. restrict visitors d. watch for early signs of infectin

a gloves should be changed when wounds on different areas of the body are handled and between handling old and new dressings

which is the priority in the preparedness of health care professionals in any type of disaster plan a. identification of hazards b. cooperation with state authorities c. collaboration with local authorities d. implementation of federal mandates

a identification of hazards is the priority in the preparedness of health care professionals in any type of disaster plan

which are the priority nursing actions after the completion of the secondary survery when providing care for a trauma pt with a penetrating wound a. documeting pt care b. formulating the pt plan of care c. reassessing the pt LOC d. transferring pt to the general medical unit

a priority action after completion of the secondary survey during the emergency assessment include documenting all patient care and administering tetanus prophylaxis

the nurse is preparing an educational tool to instruct community members on burn prevention. what should the nurse include as the most common injury in child under age 5 a. scald b. flame c. chemical d. carbon monoxide poisoning

a scald injuries are most prevalent in children under the age of 5

a patient with several deep partial thickness burns asks how long it will take for the burn to heal. what should the nurse respond to this patient a. more than 2 weeks b. within one to two weeks c. within 24 to 72 hours d. you will need skin grafts

a the majority of deep partial thickness burns take more than two weeks to heal

which situation does not cover nurses who respond to a mass casualty incident for malpractice or negligent lawsuits under the good samaritan act a. terrorist act b. neighborhood fire c. roadside care accident d. high school sporting event

a when terrorist attacks occur nurses are often required to go to an assigned site to offer aid. when this occurs the nurse is not covered from malpractice or negligent lawsuits

which member of the healthcare team when using the team nursing approach, is responsible for prioritizing patient care a. team leader b. charge nurse c. LPN d. UAP

a when using the team nursing approach the team leader who is a RN is responsible for coordinating a group of licensed and unlicensed personnel to provide patient care to a small group of patients, including the prioritization of patient care

A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A. Encouraging participation in wound care B. Encouraging visitors C. Reassuring the client that he or she will be fine D. Telling the client that these feelings are normal

a Encouraging participation in wound care will offer the client some sense of control. Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? A. Give oxygen per facemask .B. Infuse lactated Ringer's solution at 150 mL/hr. C. Give morphine sulfate 4 to 10 mg IV for pain control. D. Insert a 14 Fr retention catheter.

a Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level. Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.

the nurse is helping a training plan to familiarize health care providers with emergency response procedures. which training measure is most effective to adequately prepare the trainees a. drills b. tabletop exercises c. access to the policy d. computer simulations

a Hospital disaster drills are priority training measures to familiarize health-care providers with emergency response procedure.

the nurse administrator for a LTC is implementing a disaster response plan for staff and residents. which staff member statements indicate correct understanding of the plan a. we have to implement annual drills b. nursing homes are not required to have a plan c. our facility is held to the same standards as hospital facilities d. this is an important component to receive insurance payments for care

a Hospitals are not the only health-care agencies that are required to practice disaster drills. Long-term care (LTC) facilities are also mandated to have annual drills to prepare for mass casualty events. Part of the response plan must include a method for evacuation of residents from the facility in a timely and safe manner.

which organization in the united states mandates ongoing disaster preparedness for hospitals a. the joint commission b. the local government c. the state government d. OSHA

a In the United States, The Joint Commission mandates that hospitals have an emergency preparedness plan that is tested through drills or actual participation in a real event at least twice yearly.

the nurse is a member of the critical incident stress management unit that looks to meet the psychosocial needs of first responders after a mass casuality incident. which action by the nurse is appropriate when conducting a session a. arranging a group discussion' b. administering anti anxiety medication c. scheduling individual therapy appointments d. documenting individual responses to the session

a Many hospitals and DMATs have a critical incident stress management unit, which arranges group discussions to allow participants to share and validate their feelings and emotions about the experience. This is important for emotional recovery.

a green tagged pt arrives at the emergency dept after a mass casualty incident involving radiation. which is the priority nurse action for this pt a. implementing decontamination measures b. performing a head to toe physical examination c. placing a special bracelet with a disaster number d. taking a digital photo and placing it on the medical record

a The priority nursing action for a green-tagged patient who arrives at the ED after exposure to radiation is implementing decontamination measures. These measures are the priority because it is essential that members of the health-care team and patients are not exposed to the radiation while providing care.

Which action by the nurse changing the dressings on the client who has burns on the right arm, the left arm, and the upper chest is most effective at preventing auto-contamination? A. Changing gloves after cleaning and dressing one wound area before cleaning and dressing the next wound area. B. Using sterile gloves to remove the old dressings and changing to fresh sterile gloves before applying the new dressings. C. Ensuring that the blood pressure cuff used on another client is thoroughly cleaned before using it on this client. D. Warning the client's family not to bring fresh fruit and vegetables or house plants into the client's environment.

a Rationale: Auto-contamination is the movement of organisms from one body area on a client to another body area. The use of sterile versus clean gloves for routine wound care varies by agency and is a matter of debate. Regardless of sterility, change gloves when handling wounds on different areas of the body and between handling old and new dressings. So, if the nurse changed to fresh gloves after removing old dressings but kept the fresh gloves on while dressing all the burn wound areas, he or she greatly increases the risk for translocating organisms from one burn wound to another, resulting in auto-contamination. Responses C and D address cross-contamination that occurs between people.

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? A. In a neutral position B. In a position of comfort C. Slightly flexed D. Slightly hyperextended

a The neutral (extended) position is the correct placement of the elbow to prevent contracture development. Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.

the nurse is conducting triage under mass casualty conditions. which tag should the nurse use for a patient who is experiencing hypovolemic shock due to a penetrating wound a. red b. black c. green d. yellow

a The nurse would use a red tag for a patient who has injuries that are an immediate threat to life, such as hypovolemic shock, during mass casualty conditions.

which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device a. covering the nose b. protecting the eyes c. decontaminating the skin d administering prophylactic antibiotics

a The priority nursing action to protect against the radioactive dust and smoke that can cause illness from an RDD is covering the nose and the mouth to decrease the risk for inhalation.

The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A. Reduction of bacterial growth in the wound and prevention of systemic sepsis B. Prevention of cross-contamination from other clients in the unit C. Enhanced cell growth D. Reduced need for a skin graft

a Topical antimicrobials such as silver sulfadiazine are an important intervention for infection prevention in burn wounds. Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.

the nurse manager is reviewing the hospital disaster plan with other members of the comittee. which is the minimum number of disaster drills the commitee must plan and implement each year a. two b. three c. four d. five

a While it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year.

a medical-surgical unit is expecting a large volume of patient admissions after a trail derailment. which member of the nursing care team will prioritize care for the unit a. charge nurse b. nurse supervisor c. LPN d. UAP

a a charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual patient; therefore it is this member of the team that will prioritize care for the patients who are being admitted

a patient with 35% total body surface area burns is in the rehabilitative phase of care. which approach should be used to reduce the risk of developing contractures a. apply splints b. physical therapy two hours a day c. passive range of motion exercises d. occupational therapy one hour every other day

a splinting is the most common method used to prevent contractures

which nursing actions are necessary when initiating care for pt who have been injured in a natural disaster a. taking risks b. using principles c. stepping into the unknown d/ showing a commanding presence e. formulating individualized plans of care

a b c d This is correct. Nursing actions that are required when initiating care for patients who have been injured in a natural disaster include taking risks, using principles, stepping into the unknown, and showing a commanding presence.

a pt is dx with several superficial partial thickness burns. what tx would be indicated for this patient a. apply bacitracin ointment b. cover with a nonadherent bandage c. apply mafenide acetate 10% cream d. wash with antiseptic soap and warm water e. apply collagenase and cover with roll guaze

a b d

which threats included in the term NBC lead to the implementation of improved emergency medical services (EMS) and hospital safety programs a. nuclear b. biological c. botulism d. chemcal e. nipah virus

a b d the term NBC was coined to describe nuclear biological and chemical threats

a patient has been recovering for 18 months from burns that affected 60 % total body surface area. for which problems should the nurse anticipate providing continuing care to this patient a. anxiety b. depression c. spiritual distress d. body image disorder e. PTSD

a b d e

the nurse is caring for a patient who sustained chemical burns. what would have caused these injuries. SATA

a b d e lime can cause a chemical burn, gasoline can cause a chemical burn, bleach can cause a chemical burn, and hydroflouric acid can cause a chemical burn

which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan SATA a. treatment b. stabilization c. evaluation of interventions d. formulation of nursing diagnosis e. decontamination for suspected contamination

a b e This is correct. Victims need to be treated and stabilized and, if there is known or suspected contamination, decontaminated at the scene.

a nurse is working an evening shift when a fire breaks out at the hospital. which actions by the nurse are appropriate a. removing patients from immediate danger b. discontinuing the use of oxygen for all patients c. using a wheelchair to move a bedridden patient d. directing ambulatory patients to walk to a safe location e. containing the fire immediately to avoid pt evacuation

a c d This is correct. According to the fire safety portion of the emergency response for internal disasters, the nurse should remove patients from immediate danger, use a wheelchair to move bedridden patients, and direct ambulatory patients to walk to a safe location.

the school nurse is preparing material for National Fire Prevention week. what information should be added to the classroom posters. SATA a. never leave a burning candle unattended b. set heating pads on low when sleeping c. keep a flashlight and telephone near the bed d. check smoke alarm batteries every 6 months e. never use the oven as a method to warm the home

a c d e

Which factors indicate that a client's burn wounds are becoming infected? (Select all that apply.) A. Dry, crusty granulation tissue B. Elevated blood pressure C. Hypoglycemia D. Edema of the skin around the wound E. Tachycardia

a d e Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection. Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

which are the top priorities when conducting a primary patient survey during the emergency assessment a. airway b. disability c. breathing d. circulation e. cervical spine

a e airway and stabilization of the cervical spine are the TOP priorities when conducting a patient survey

which is a potential life threatening condition found during the primary triage survey that would necessitate priority nursing care a. cystitis b. concussion c. lacerated arm d. fractured femur

b a concussion which a type of head injury is a potentially life threatment condition found during the primary triage survery that would necessitate priority nursing care

the nurse is conducting a primary survery during the emergency assessment. which nurse action is appropriate during the breathing assessment a. assessing for edema b. counting respiratory rate c. checking for foreign bodies d. monitoring for respiratory distress

b

a patient has full thickness burns over 30% of total body surface area. which intervention will least likely provide comfort initially to this patient a. elevate injured extremeties b. medicate for pain around the clock c. apply medicated ointment to all areas d. elevate the HOB to 30 degrees

b a full thickness burn involves destruction of the epidermis, the dermis, and portions of the subcutaneous tissue. all epidermal and dermal structures are destroyed including hair follicles, sweat glands, and nerve endings. as a result of the extensive damage to the nerve endings, full thickness burns are insensate to palpation and often are not painful. pain medication would be least likely to provide comfort to this patient

the nurse is evaluating nutritional teaching provided to a patient recovering from 24% total body surface area burns. which information indicates that teaching has been effective a. weight loss 3 kg b. serum protein 7.1 d. serum albumin 2.8 d. +1 pitting edema of lower extremeties

b a normal serum protein level is 6.4 to 8.3

a patient with deep partial thickness wounds is receiving enymatic debridement. what assessment made by the nurse would indicate that wound care treatment has been successful a. gray wound bed b. separation of eschar c. development of eschar d. presence of purulent exudate

b enzymatic debridement involves the application of a proteolytic ointment that hastens eschar separation

which is the priority nursing action when providing care to a pt with a penetrating abdominal wound a. assessing bowel sounds b. stabilizing the impaled object c. administering prescribed pain medication d. scheduling a ct scan to determine retro peritoneal bleeding

b priority is stabilizing the impaled object to prevent further injury

which is the essential nursing skill for the triage process in the emergency dept a. evaluating care b. setting priorities c. formulating diagnoses d. implementing interventions

b setting priorities is essential skill for the triage, or assessment process that occurs in the emergency dept

which observation indicates that interventions provided to a pt with neck injuries from a MVA have been successful a. urine is clear and odorless from catheter b. moves all 4 extremeties independently, feeds self, and participates in partial bath c. unable to move independently in bed d. rests in bed with lights and television turned off

b the pt sustained neck injuries from a MCA< with these injuries there is a risk for paralysis.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A. "The last tetanus injection was less than 5 years ago." B. "Burn wound conditions promote the growth of Clostridium tetani." C. "The wood in the fire had many nails, which penetrated the skin." D. "The injection was prescribed to prevent infection from Pseudomonas."

b Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the client is admitted to the hospital. Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent Pseudomonas infection.

which wound assessment characteristics suggest a superficial partial-thickness burn injury? A. Black-brown coloration B. Painful C. Moderate to severe edema D. Absence of blisters

b Characteristics of a superficial partial-thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters. A black-brown coloration is more suggestive of full-thickness burn injury. Moderate to severe edema and absence of blisters may be present with deep partial-thickness to full-thickness burn injuries.

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? A. Intramuscular B. Intravenous C. Sublingual D. Topical

b During the resuscitation phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.

which emergency medical system (EMS) first responders can perform triage during mass casualty incidents a. UAP b. nurses appointed to a field team c. a physician who survives the incident d. community response team members

b Paramedics and nurses appointed to a field team are the EMS first responders who can perform triage during a mass casualty incident.

Which client response does the nurse interpret as an indication of fluid resuscitation adequacy? A. Decreasing pulse pressure B. Decreasing urine specific gravity C. Decreasing core body temperature D. Increasing respiratory rate and depth

b Rationale: Urine output is the most sensitive noninvasive measure of fluid resuscitation adequacy. An increase in urine output is a positive sign; however, so is a decreasing urine specific gravity. As urine output increases, the concentration of the urine decreases, leading to a decreased urine specific gravity. A decreasing pulse pressure often indicates a fall in systolic pressure, which would not indicate fluid resuscitation adequacy. A decreasing core body temperature is related to changes in the inflammatory response or metabolism and not an indication of fluid resuscitation adequacy. An increasing respiratory rate could indicate pulmonary edema but not fluid resuscitation adequacy. The increased respiratory depth may indicate other positive changes but not adequacy of fluid resuscitation.

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? A. Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C. An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D. Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

b Smoke inhalation and facial burns are associated with airway inflammation and obstruction; the client with difficulty breathing needs immediate assessment and intervention. Although the client admitted a week ago with deep partial-thickness burns is reporting pain, this client does not require immediate assessment. The electrician who suffered burn injuries a month ago is stable and has been in the burn unit for a month, so the client's condition does not warrant that the nurse should assess this client first. The older adult client admitted yesterday with burns over 40% of the body is stable; he is receiving IV fluids and does not need to be assessed first.

several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? A. Middle-aged adult who is frantically explaining to the nurse what happened B. Young adult who suffered burn injuries in a closed space C. Adult with burns to the extremities D. Older adult with thick, tan-colored sputum

b The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

The nurse is caring for a client with burns to the face. Which statement by the client requires further evaluation by the nurse?A. "I am getting used to looking at myself."B. "I don't know what I will do when people stare at me."C. "I know that I will never look the way I used to, even after the scars heal."D. "My spouse does not stare at the scars as much now as in the beginning

b The statement about not knowing what to do when people stare indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques. Visits from friends and short public appearances before discharge may help the client begin adjusting to this problem. The statement that the client is getting used to looking at himself or herself, the realization that he or she will always look different than before, and stating that the client's spouse doesn't stare at the scars as much all indicate that the client is coping effectively. Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns.

which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident a. less than ten seconds b. less than 15 seconds c. less than 30 seconds d. less than 60 seconds

b Triage of victims of an emergency or an MCI must be conducted in less than 15 seconds. The other time frames, 10 seconds, 30 seconds, and 60 seconds, are not accurate.

the nurse is caring for a patient with 70% total body surface area chemical burns. which approach should the nurse anticipate to meet this patients nutritional needs a. parenteral nutrition b. duodenal tube feedings c. nasogastric tube feedings d. six small high caloric meals per day

b in large burn injuries, longer nutritional support is required, and placement of a duodenal feeding tube is often recommended to help prevent aspiration and allow for feeding up and during procedures

a pt recovering from full thickness burns rates pain as a 9 on a scale of 0 to 10 when hydrotherapy is performed. for which type of pain should this patient be treated a. referred b. procedural c. background d. breakthrough

b the procedural pain is associated with therapeutic activities such as wound care and physical therapy

which are the most common types of injuries that should be identified along with tx options in an organizational disaster plan for the plan for the use of explosive devices as agents terrorism a. burn b. blast c. crush d. penetration e. psycological

b c e This is correct. Blast, crush, and penetration injuries are most common when explosive devices are used as an agent of terrorism. These injuries should be identified in the organizational disaster plan along with appropriate treatment options for each.

which nursing actions are apprioriate during the primary survey of the emergency assessment process a. inserting a NG tube b. immobilizing the cervical spine c. arranging for diagnostic studies d. preparing for chest tube insertion e. applying direct pressure to a wound

b d e the primary survey focuses on airway breathing circulation disability and exposure or environmental control, it aims to identify life threatening conditions

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? (Select all that apply.) A. Provides cushions and rugs for comfort B. Performs frequent handwashing C. Places plants in the client's room D. Performs gloved dressing changes E. Uses disposable dishes

b d e Handwashing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection. Disposable items (e.g., pillows, dishes) are used as much as possible. Cushions and rugs are difficult to clean and may harbor organisms, and so are not provided. To avoid exposure to Pseudomonas, having plants or flowers in the room is prohibited.

the nurse is providing care to several patients in the ED. which patient would require priority care from the nurse a. an adult patient with an ankle sprain b. an infant with a rash unknown orgin c. an adult pt with unstable vital signs and chest pain d. a pediatric pt with multiple fx following a MVA

c

A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? A. "Do you want to pray about it?" B. "I know, and you will have to learn to adapt to a new body image." C. "Tell me more." D. "There must be a reason."

c Asking the client to tell the nurse more encourages therapeutic grieving. Offering to pray with the client assumes that prayer is important to the client and does not allow for grieving; the nurse should never assume that the client is religious. The response, "I know, and you will have to learn to adapt to a new body image" only serves to add stress to the client's situation. The response, "There must be a reason" minimizes the grieving process by not allowing the client to express his or her concerns.

which tx for anthrax should be included in the biological agent portion of a disaster plan for terrorist attacks a. antivirals b. antitoxins c. antibiotics d. vaccinations

c anthrax is tx effectively with antibiotics if sufficient supplies are available and the organisms are not resistant

a patient recovering from deep and full thickness burns is nauseated. which medication should the nurse provide to help this patient a. ranitidine (zantac) b. esomeprazole (nexium) c. retoclopramide (reglan) d. polyethylene glycol (miralax)

c metoclopramide (reglan) promotes stomach emptying and decreases nausea

a victim of a house fire is brought to the ED for burn treatment. what assessment finding indicates that the patient may have an inhalation injury a. coughing b. soot on the face c. singed facial hair d. HR 98 BPM

c patients with an inhalation may present with singed facial hair

a patient is ending the first year of recovery after having burns to both legs. which observation indicates that the patient needs to be encouraged to wear the pressure garment a. skin warm and moist b. pedal pulses present but faint c. scattered areas of scarring noted d. nonpitting edema of both ankles

c specialty pressure garments are intended to provide continous and uniform pressure over the area of burn to prevent hypertrophic scarring. these garments are to be worn 23 hours a day for up to a year or more after injury in some patients. the presence of scarring indicates the garment has not been worn consistently

a patient comes into the ER seeking tx for radiation burns. what should be considered prior to providing care through this patient a. pathway of flow through the body b. duration of contact with the agent c. type, dose, and length of exposure d. temperature to which the skin is heated

c the severity of a radiation burn is dependent upon the type, dose and length of exposure

a patient with 55% of total body surface area burned received two -thirds of the required fluid resuscitation. for which potential problem should the nurse prepare to provide care to this patient a. increased zone of stasis b. increase zone of hyperemia c. increased zone of coagulation d. decreased zone of coagulation

c the zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. it is this area of the burn that is most at risk for conversion if the patient does not receive adequate resuscitation. improper resuscitation or under resuscitation may cause the burn to become deeper because of limited blood flow, causing the zone of stasis to convert into the zone of coagulation

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? A. Bowel sounds are absent. B. The pulse oximetry level is 91%. C. The serum potassium level is 6.1 mEq/L. D. Urine output since admission is 370 mL.

c An elevated serum potassium level can cause cardiac dysrhythmias and arrest, and so is of the most concern. Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.

The nurse is caring for a client with burns. Which question does the nurse ask the client and family to assess their coping strategies? A. "Do you support each other?" B. "How do you plan to manage this situation?" C. "How have you handled similar situations before?" D. "Would you like to see a counselor?"

c Asking how the client and family have handled similar situations in the past assesses whether the client's and the family's coping strategies may be effective. "Yes-or-no" questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage; asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.

which health care team member is a first responder when an emergency of mass casualty incident occurs a. fireman b. policeman c. critical care nurse d. UAP

c Critical care nurses are often considered emergency medical personnel that respond to emergency or MCIs.

a nurse manager is a member of the emergency response planning team for a hospital located in the rocky mountains. which type of natural disaster will the nurse manager recommend be included in their disaster plan a. tornado b. hurricane c. avalanche d. earthquake

c Disaster drills are ideally planned based on a risk assessment or vulnerability analysis that identifies the events most likely to occur in a particular community. For a hospital in the Rocky Mountains, there is a significant risk for an avalanche. The nurse manager will, therefore, recommend that avalanche planning be included in the hospital disaster plan.

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A. Blood urea nitrogen (BUN), 36 mg/dL B. Creatinine, 2.8 mg/dL C. Urine output, 40 mL/hr D. Urine specific gravity, 1.042

c Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL/hr or 0.5 mL/kg/hr. A BUN of 36 mg/dL is above normal, a creatinine of 2.8 mg/dL is above normal, and a urine specific gravity of 1.042 is above normal.

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A. Intense pain B. Potential for inadequate oxygenation C. Reduced self-image D. Potential for infection

c In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? A. Pale, boggy, dry, or crusted granulation tissue B. Increasing wound drainage C. Scar tissue formation D. Sloughing of grafts

c Indicators of wound healing include the presence of granulation, re-epithelialization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.

what strategy does the nurse include when teaching a college student about fire prevention in the dormitory room a. use space heaters to reduce electrical costs b. check water temp before bathing c. do not smoke in bed d. wear sunscreen

c Smoking in bed increases the risk for fire because the person could fall asleep. Use of space heaters may increase the risk for fire, especially if they are knocked over and left unattended. Checking water temperature does not prevent fires, but it should be checked if the client has reduced sensation in the hands or feet. Sunscreen is advised to prevent sunburn.

A client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A. Range-of-motion exercises B. Emotional support C. Fluid resuscitation D. Sterile dressing changes

c The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? A. Bowel sounds B. Muscle strength C. Signs of infection D. Urine output

c The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery. Assessing bowel sounds, assessing muscle strength, and assessing urine output are important but not the priority during the acute phase of burn injury.

the nurse is a first responder for health care organization for a mass casualty incident. which injury would the nurse tag as yellow during the triage process a. ankle sprain b. hypovolemic shock c. open femur fx d. massive head trauma

c When using a triage tag system, an open femur fracture is an urgent but not life-threatening injury that would be tagged as yellow.

the nurse is caring for a patient with 45% total body surface area thermal burns. which laboratory value change would be expected a. increased pH b. increased sodium c. increased potassium d. decreased hematocrit

c hyperkalemia is expected because of massive cellular trauma causing the release of potassium into extracellular fluid

which psychosocial nursing actions are appropriate when providing patient are after a community disaster a. performing triage of injuries b. administering first aid to wounds c. offering choices when possible d. establishing rapport through active listening e. requesting assistance from crisis counselors

c d e This is correct. Psychosocial nursing actions appropriate when providing care after a community disaster include offering choices whenever possible, establishing rapport through active listening, and requesting assistance from crisis counselors.

a patient is providing care to several patients in the emergency dept. which patient would require priority care when using the three tiered simple fx a. a patient with a simple fx b. a patient experiencing renal colic c. a pt with severe abdominal pain d. a pt with chest pain and diaphoresis

d

which assessment data related to the pt airway would indicate the need for priority intervention by the nurse a. eupnea b. tachycardia c. hypotension d. agonal breaths

d

the nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. which test would be a priority for this patient a. chest xray b. bronchoscopy c. ct scan of the head d. 12 lead electrocardiogram

d a 12 lead electrocardiogram is indicated for an electrical burn

it is documented that a patient has superficial partial-thickness burns over both anterior lower arms. what should the nurse expect when assessing this patient a. dry with no blisters b. waxy appearance and cherry red in color c. dry leathery appearance and pale or brown in color d. open or closed blisters, mild edema, easily blanches

d a superficial partial thickness burn has blisters that may be closed or open and weeping, pink or red, mild edema, and blanches easily

the ED nurse is triaging patients. which patient should be prioritized a. an adult patient experiencing mild chest pain b. an adolescent patient with a possible fx wrist c. an older patient with a hip fx who is in patient d. a school age patient with asthma presenting with dyspnea

d according to the five level emergency severity index a patient experiencing severe respiratory distress is priority

which nursing action is appropriate when conducting a secondary survery during the emergency assessment a. maintaining privacy b. having suction available c. giving supplemental oxygen d. assigning a nurse to support family members

d all other interventions are to be done during primary

what should the nurse do to assist a patient brought to the ED as a victim of a gunshot wound a. ask the patient who shot him b. bathe the pt and provide a clean gown c. ask the patient where the weapon is d. preserve the chain of evidence

d because the majority of gunshot wounds require an investigation by law enforcement, nurses work in ED and trauma centers should be familiar with their agencys protocols for maintaining evidence required by law enforcement. often law does not want the victims lands or the area around wounds cleaned. clothes/personals are wanted for evidence

which is the critical factor among health care professionals, stage agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster a. cooperation b. classification c. collaboration d. communication

d communication is the critical factor among health-care professionals, state agencies, and federal agencies to determine when and how to evacuate safety during a natural disaster.

a patient is admitted for a suspected inhalation injury. what should the nurse emphasize when caring for this patient? a. increase oral fluids b. turn in bed every 2 hours c. monitor strict intake and output d. deep breathing and coughing every hour

d deep breathing and coughing should be done every hour to assist with airway clearance and mobilization of secretions

an 11 year old child received burns over both upper and lower arms, both hands, anterior upper and lower legs,anterior chest and the neck. using the following as a guide. what is this childs total body surface area burned a. 30% b. 42% c. 57% d. 65%

d for 10-14 year old the neck is 2, the anterior trunk is 13, the right upper arm is 4, the right lower arm is 3, the upper left arm is 4, the left lower arm is 3, the right hand is 2.5, the left hand is 2.5, the right thigh is 9 and the left thigh is 9, the right lower leg is 6.5 and the left lower leg is 6.5 total equals 65%

the nurse is evaluating care provided to a patient with burns during the emergent phase. which data indicates the need for additional fluid resuscitation a. blood pH 7.39 b. heart rate 112 bpm c. BP 110/60 d. central venous pressure 2mmHg

d indications of adequate fluid resuscitation include a central venous pressure between 5-10 mmHg. a pressure of 2 mmHg indicates fluid volume deficit. more fluid would be indicated

the nurse is caring for a patient who sustained electrical burns. why should the nurse monitor this patient for compartment syndrome? a. potential for undiagnosed injuries b. injuries from being thrown bruise soft tissue c. electrical current alters integrity of blood vessels d. fluid seeps from an intravascular spaces into the interstium

d pulses are closely monitored in all affected extremeties for the first 48 hours postinjury in order to assess for the potential devlopment of compartment syndrome. as fluid seeps from the intravascular spaces into the insertitium pressure within the tissues continue to rise and confines inside muscle compartments

which pt injury would receive a black tag by the triage nurse during a mass casualty incident a. concussion b. ankle sprain c. open femur fx d. full thickness body burns

d A black tag indicates the patient has suffered an extensive injury and is expected, or allowed, to die. Typical examples of black-tagged patients are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation.

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit? A. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B. Recently admitted client with a high-voltage electrical burn C. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D. Client receiving IV lactated Ringer's solution at 150 mL/hr

d An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, and so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr. The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% TBSA burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries.

which entity is responsible for activating the disaster plan during a mass casualty incident MCI a. local emergency management system b. state emergency management system c. federal emergecy management agency d. hospital level emergency management system

d Each hospital has its own policy that specifies who has the authority to activate and how to activate the disaster or emergency preparedness plan.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? A. Discouraging having food brought in from the client's favorite restaurant B. Providing more palatable choices for the client C. Helping the client lose weight D. Planning additions to the standard nutritional pattern

d Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance. It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight.

For which type of burn injury is it most important for the nurse to assess the client for a respiratory injury?A. Hot liquid scald burnB. Liquid chemical burnC. Electrical burnD. Dry heat burn

d Rationale: Direct injury to the lung from contact with flames, scalding hot liquids, liquid chemicals, or electrical current rarely occurs. Rather, respiratory problems are caused by superheated air, steam, toxic fumes, or smoke. Although it is possible for an electric current to pass through the lungs, it seldom causes injury.

a workplace violence prevention plan is often one component of a hospital disaster plan. which unit assumes priority for implementation and evaluation of this component to the plan

d The Emergency Nursing Association (ENA) supports comprehensive workplaceviolence prevention plans to be included as a component of the organizational disaster plan. The ENA recommends that the comprehensive workplace violence prevention plan be implemented and evaluated in every emergency department.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? A. Administer a diuretic. B. Provide a fluid bolus. C. Recalculate fluid replacement based on time of hospital arrival. D. Titrate fluid replacement.

d The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids). A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

the nurse is caring for a pt with 50% total body surface area burns. which finding indicates that burn shock is resolving a. HR 112 BPM b. respirations 24 per minute c. BP 90/60 d. urine output 800 ml over 2 hours

d in the postburn shock phase, which begins 24-48 hours after injury the capillaries begin to regain integrity. burn shock slowly resolves and the fluid gradually returns to the intravascular space. urinary output continues to increase secondary to patient diuresis

The nurse is triaging clients arriving at the hospital after a large scale disaster. Which of these clients is correctly classified? A. Young adult with closed fractures of her right leg and arm: Yellow tag B. Older adult with severe abdominal pain who is dazed and confused: Black tag C. Middle-aged adult with third-degree burns over 90% of his body: Red tag D. Young adult with bruises and superficial lacerations: Green tag

d The young adult with bruises can walk and get away from the disaster; this is characteristic of green tag clients. The young adult with fractures should be classified as green, the older adult with severe abdominal pain should be classified as yellow, and the middle-aged adult should be black-tagged as there is no chance for survival with that injury.

which public health risk became a major focus for hospitals after the september 11, 2001 terrorist attacks a. anthrax exposure b. multi casuality incidents c. mass casualty incidents d. weapons of mass destruction

d Weapons of mass destruction (WMD) rapidly became a focus of public health risk after the terrorist attacks that occurred on September 11, 2001.

a victim of a car fire is confused, dizzy and nauseated. what diagnostic test should be done to determine if the patient is experiencing carbon monoxide poisoning a. chest xray b. bronchoscopy c. pulse oximeter d. carboxyhemoglobin level

d because carbon monoxide binds to the hemoglobin molecule with an affinity 200 times greater than that of oxygen, tissue hypoxia results when carbon monoxide levels are greater than normal. carboxyhemoglobin levels will detect the amount of carbon monoxide in the patient