DAVIS TEST 5

1057. A nurse who is initiating an intravenous infusion of lactated Ringer's (LR) for a client in shock recog- nizes that the purpose of LR for the client is to: 1. increase fluid volume and urinary output. 2. draw water from the cells into the blood vessels. 3. provide dextrose and nutrients to prevent cellular death. 4. replace electrolytes of sodium, potassium, calcium, and magnesium for cardiac stabilization.

1

277. A nurse is caring for a 3-year-old burn victim who is the only child of a single parent. The parent has not visited the child for 2 days, and the child is crying and says, "I want my mommy! Where is she?" The nurse calls the parent, who says, "I cannot stand to see my baby in so much pain knowing that I am responsible for this." The best response of the nurse is: 1."It sounds like you are feeling guilty. Can you come in to talk about how we can help you and your child?' 2."I am sorry you are feeling responsible. I just wanted to know when you could be here. 3."It is very important that your child see you. How can I help you to get here?" 4."Why do you think that you are responsible for this?"

1

A nurse is caring for a 5-year-old child with secondary burns over 40% of the body. The child has just been diagnosed with disseminated intravascular coagulation (DIC). Which is the priority nursing diagnosis based on the most recent condition? 1. Ineffective tissue perfusion 2. Impaired urinary elimination 3. Risk for deficient fluid volume 4. Impaired physical mobility

1

A nurse is developing an educational program targeting parents of toddlers. The nurse should be able to present information aimed at preventing the majority of burn injuries in toddlers. Which is the most common cause of burns in toddlers? 1. Pulling pans of scalding liquid from the stove 2. Touching a curling iron 3. Burns from flames 4. Exposure to lighted candles

1

A nurse is to administer vancomycin (Van- cocin®) to a client diagnosed with sepsis. The client is to have a peak and trough level completed on this dose of the medication. Which action should the nurse initiate first? 1. Determine if the trough level has been drawn on the client. 2. Determine medication compatibilities before infusing into an existing intravenous line. 3. Check the client's culture and sensitivity (C&S) report. 4. Check the amount of time over which the medication dose should infuse.

1

1280. A nurse assesses the hand of a child who experi- enced a thermal burn from scalding (see exhibit). Which interventions should the nurse plan when caring for the child? SELECT ALL THAT APPLY. 1; Administer analgesics prior to burn care. 2. Insert gauze between fingers. 3. Pierce blisters prior to dressing the hand 4 Secure any dressings applied with netting: 5. Apply lotion to keep hand moist

124

Which interventions should a nurse implement to assist a client with problems of anxiety and confu- sion in the critical phases of burn injury? SELECT ALL THAT APPLY. 1. Repeat statements of orientation to person, place, and time with the client. 2. Turn the client every 2 hours for reorientation. 3. Place familiar objects brought from home nearby so the client can touch them. 4. Implement a schedule for regular sleep/wake cycles. 5. Keep the door of the room closed so that distractions can be controlled. 6. Encourage the client to write notes to family members.

134

1275. A nurse is caring for a 7-year-old client who has been hospitalized for several days with severe burn injuries in the lower extremities. On initial examina- tion, the nurse makes the following assessments regarding the client's right leg: distal pulses are weak, capillary refill is greater than 3 seconds, and the child reports feelings of numbness and tingling in the leg. What should be the nurse's interpretation of this information? 1. This is to be expected during this phase of burn healing. 2. This is an emergency situation and a health-care provider should be notified. 3. Comparative assessment of the extremity in 1 hour is necessary. 4. Fluid has accumulated under the scab of the burn and is decreasing blood flow to the area.

2

1279. A nurse is planning the discharge of a pediatric burn victim to the child's home. The child is able to ambulate with assistance but is cognitively and developmentally unable to function at the age- appropriate milestones due to asphyxiation. Which component should the nurse include as most impor- tant in the discharge planning of this child? 1. Identifying support groups for the child's parents 2. Coordinating care and services for the child's rehabilitation 3. Assessing the child's home for safety concerns 4. Communicating with the school to ensure that the child will receive mandated services

2

758. A nurse cares for a client with a venous leg wider who undergoes trilayer artificial skin grafting. The nurse understands that grafted skin heals best on venous leg ulcers when which intervention is implemented after grafting? 1. Applying a gauze dressing 2. Applying compression bandages 3. Applying Xeroform® dressing 4. Applying petrolatum bandages

2

A new nurse asks an experienced nurse during a child's dressing change, after the child had a skin graft, why the skin appears lattice-like and not smooth like the unburned areas of the child's body. Which is the experienced nurse's best response? 1."The skin is an allograft from a cadaver donor, and the freezing of the skin causes this appearance. 2. "The skin is an autograft from a distal, unburned portion of the child's body, but the skin was meshed so it could be stretched to cover more area." 3. "After the grafting procedure, the area is covered by a bulky dressing. The lattice-like appearance is from the indentations of the dressing. 4 The fluids that seep through the child's tissues cause the new skin to stretch and separate, but as it heals, the skin pulls back together."

2

A nurse is in an emergency department when a parent calls sobbing hysterically and stating, "My baby has just put an electrical cord in her mouth! What do I do?" Which statement or question identi- fies the first priority of the nurse? 1. Call 911 and have them bring your baby to the emergency department." 2."Have you removed the cord from the baby mouth?' 3."Is there bleeding at or around the mouth?» 4 What does your baby's mouth look like?"

2

752. A nurse is assessing the fluid status of a client with a second-degree burn who weighs 60 kg. The client is 5 hours postburn. The nurse determines that the client's fluid status is inadequate and immediately notifies a physician when the client exhibits: 1.blood pressure 92/60 mm Hg and pulse rate 100 beats per minute (bpm). 2. respiratory rate 18 breaths per minute and pulse rate 60 bpm. 3. pulse rate 130 pm and urine output 25 mL/hr. 4. pulse rate 106 bpm and temperature 98.4°F (36.9°C).

3

A 2-year-old child has a bulky dressing in place over 60% of the child's body following a skin-grafting procedure for a severe burn injury. A parent arrives to visit the child and is shocked to see the child's appearance. Which is the most caring action for a nurse? 1. Help the parent don the mask, gown, and gloves that are required to enter the child's room. 2. Bring the parent to a quiet place to allow the parent to talk about immediate concerns. 3. After the parent is appropriately attired, take the parent into the room and show the parent that it is okay to stroke the child's face and hold the child's hand. 4. Arrange for a member of the clergy to come visit with the parent for support.

3

A child is presenting with burn injuries. What should be the nurse's priority during the initial assessment? 1. Inspect location, extent, and shape of burn injuries. 2. Assess the child's and family's concerns regarding the child's appearance. 3. Assess for signs of smoke inhalation and burns to the face and neck. 4. Assess for signs and symptoms of infection.

3

A nurse is assessing a 16-year-old adolescent in an emergency department who has been admitted be- cause of burns over 25% of the client's body. Upon initial examination, the nurse makes several observa- tons, Which observation should be most concerning to the nurse? 1. Areas on upper extremities are mottled. 2. Areas on upper extremities are moist and red. 3. Areas on lower extremities are waxy white. 4. Red blistering on anterior lower extremities.

3

A nurse is assessing a child who is presenting with burn injuries. Which injuries would least likely trigger the need for further assessment or evaluation for the potential of child abuse and mandatory reporting? 1. Rope burn with edema 2. Cigarette burns 3. Splash burns on the front torso, face, and neck 4. Scald burns of the feet and legs

3

A nurse is assessing a client following a skin graft. The nurse should suspect infection in the grafted wound when observing that the client has: 1. a white blood cell count (WBC) of 9.9 K/uL. 2. serosanguineous drainage. 3. elevated temperature. 4. decreased urine output.

3

A nurse is caring for a client with a large, open sternal wound resulting from a burn injury. The client is receiving enteral feeding, Oxepa® (an anti- inflammatory, pulmonary 1.5 Cal/mL formula), at 25 mL/hour. Which abnormal laboratory value, reported in the exhibit below, indicates that the client is receiving inadequate nutrition? Phosphorus Platelets Pre-albumin Potassium 1. Phosphorus 2. Platelets 3. Pre-albumin 4. Potassium

3

In planning the care for a client recovering from second- or third-degree burns, which psychosocial nursing diagnosis should have the highest priority? 1. Disturbed sensory perception 2. Disturbed thought processes 3. Disturbed body image 4. Disturbed personal identity

3

Which medication should a nurse apply topically in second- and third-degree burns to treat bacterial and yeast infections? 1, Bismuth subsalicylate (Kaopectate®) 2. Gold sodium thiomalate (Aurolate®) 3. Silver sulfadiazine (Silvadene®) 4. Arsenic trioxide (Trisenox®)

3

A 4-year-old girl has been hospitalized for moderate burns. A nurse plans care based on knowing that the most developmentally appropriate response to the injuries and resultant treatment for a child this age is likely to be: 1. anger and hostility while trying to not appear young. 2. pushing boundaries to further autonomy. 3. wanting clear instructions regarding details of treatment. 4. believing that she is responsible for the bad things that are happening to her.

4

A nurse is caring for a toddler with second- and third-degree burns over 20% of the body 8 hours postinjury. The most critical nursing diagnosis for this patient is: 1. impaired physical mobility. 2. imbalanced nutrition: less than body requirements. 3. risk for imbalanced body temperature. 4. deficient fluid volume.

4

A nurse is reviewing orders received for a newly admitted child with second- and third-degree burns over 10% of the total body surface area (TBSA). The child weighs 20 kg. The nurse should seek further clarification from a physician when the physician's order is: 1. Ringer's lactate (RL) at 50 mL per hour for the next 8 hours. 2. insert a urinary catheter. 3. elevate the extremities above the level of the heart. 4. morphine sulfate IV prn for pain control.

4