Module 1 Post Quiz

A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the Rule of Nines.

22.5%

A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which is the initial physiologic change that the nurse can expect? A. Potassium level of 5.4 B. Blood pressure of 140/80 C. A decrease in urinary specific gravity. D. Bradypnea

A

A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? A. Crackles in the lungs B. Cyanosis C. Heart rate of 55 beats per minute D. Blood pressure 95/50

A

A client who is being discharged with severe facial scarring from burns tells the nurse, "I've saved some oxycodone, and when I get home I'm going to take all of them. Don't tell anyone." What is the best response by the nurse? A. "Are you going to kill yourself?" B. "You don't want me to tell anyone?" C. "Are you in a lot of pain right now?" D. "Do you know that too much oxycodone is dangerous?"

A

The nurse is caring for a client who sustained a partial-thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. Which primary short-term outcome established by the nurse and client will be added to the care plan? A. The client's pain will remain at 2 or less on a scale of 0 to 10. B. The client's airway will remain patent. C. The client's burns will heal free of infection. D. The client's urine output will exceed 30 ml every hour.

A

A client is brought to the emergency department with 35% TBSA burns. Which actions should the nurse implement for this client? A. Administer IVF resuscitation. B. Assess airway for patency. C. Administer IM pain medication as needed. D. Elevate extremities if no fractures are present. E. Administer oxygen as required. F. Apply a cooling blanket on the client.

A, B, D, E

Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is nothing by mouth (NPO) is complaining of severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do? A. Provide the client 4 ounces of water. B. Moisten the client's lips with oral swabs. C. Increase the rate of intravenous fluids. D. Give the client 2 ounces of orange juice.

B

Which client should the nurse see first? A. The client with a full-thickness burn to the leg from riding his motorcycle. B. The client with burns to the chest and neck while grilling. C. The client with a burn to her left hand and arm from spilling boiling water. D. The client with a chemical burn to his left leg.

B

A client is admitted to the hospital with severe burns. What client response should the nurse anticipate when caring for the client during the acute phase of burn recovery? A. High serum potassium levels B. Decreased urinary output C. Stable vital signs D. Intravascular fluid volume deficits

C

A client is recovering from full-thickness burns and the nurse provides counseling on how to best meet nutritional needs. When which foods are selected does the nurse identify that the client understands the teaching? A. Chicken noodle soup and cranberry juice B. Bacon and tomato sandwich and tea C. Cheeseburger and a chocolate milkshake D. Chicken salad sandwich and coffee

C

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? A. Oral B. Intramuscular C. Topical D. Intravenous

C

A teenage girl who has sustained a partial-thickness burn on the face secondary to excessive exposure to the sun states, "Prom night is only three weeks away. I will never be healed!" What is the nurse's best response? A. Liquid make-up base can cover the area. B. The eschar will be healed soon. C. Recovery will take approximately two weeks. D. The edema is expected for several weeks.

C

An adult client was burned in a car fire. The client sustained a circumferential burn to the right arm, the anterior torso, and half of the anterior face. What percent of the body was burned using the rule of nines? A. 15.75% B. 27% C. 29.25% D. 31.5%

C

A school-aged child is admitted to the hospital with severe burns on the arms. Therapeutic escharotomy is planned. What is the priority nursing action at this time? A. Removing blisters B. Performing passive range-of-motion exercises C. Maintaining airborne precautions D. Monitoring radial pulses

D

A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. Which intervention will the nurse complete first? A. Administering prescribed pain medication B. Inserting an indwelling catheter C. Administering oxygen D. Starting an intravenous line

D

Review the client's information below and identify the intervention to implement first. Vital Signs Temperature 97.6 orally Heart Rate: 114 Respiratory Rate: 24 Blood Pressure 98/54 Oxygen Saturation 94 on venturi mask Assessment Serous exudate from the wound Lungs clear to auscultation but diminished Urine output 20 ml for the past hours Pain rating a 5 out of 10

Pain meds