exam 4

The wound care specialist has assessed a patient's pressure ulcer and recommends using a hydrocolloid wafer to encourage autolytic debridement. The nurse would plan interventions associated with which stage pressure ulcer? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

4

The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line. How would the nurse dress this wound? 1. Hydrocolloid dressing 2. Wet-to-dry dressing 3. Alginate dressing 4. Dry, sterile dressing

4

patient with several burn scars tells the nurse that the scars are prone to injury and don't seem as tough as the rest of his skin. Which nursing response is indicated? 1. "Even when healed, the scar will only regain about 80% of the strength of normal skin." 2. "Your body is still making new blood vessels for the wound." 3. "Your body is trying to remove additional bacteria from the wound area." 4. "Your healing process hasn't been completed."

1

patient is admitted with partial-thickness burns over the entire left arm and neck. Superficial burns are present on the face and scalp. The anterior truck has patches of superficial burns. There are deep partial-thickness burns on the legs with full-thickness burns on both feet. The nurse using the Lund and Browder chart to estimate the total body surface area burned will include the burns on which body areas? Select all that apply 1. Left arm 2. Face 3. Legs 4. Feet 5. Trunk

1,3,4

The nurse assesses a burn patient's urine to be reddish-brown in color. Which interventions would the nurse anticipate? Select all that apply 1. Interventions to raise the urine pH to an alkaline level 2. Discontinuing orders for sodium bicarbonate 3. Irrigating the patient's bladder with a sodium bicarbonate solution 4. Management of intravenous fluids to achieve a urine output of 75 mL per hour 5. Monitor for hypocalcemia.

1,5

The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated? 1. Encourage the patient to ingest more fluids. 2. Assess for pain and warmth. 3. Cover the wound with a sterile dry dressing. 4. Dress the wound as prescribed.

2

The nurse is caring for a patient admitted with thermal burns. The nurse will plan to monitor the patient closely over the next 2 to 3 days for development of which most serious complication? 1. Pain 2. Burn shock 3. Continuation of the burn process below the level of obvious injury 4. Hypervolemia

2

A nurse documents a stage 1 pressure ulcer on a patient's lateral malleolus. What assessment findings would indicate that this ulcer has progressed to stage II? Standard Text: Select all that apply. 1. The subcutaneous fat layer is exposed. 2. A fluid-filled blister is present. 3. A shallow open ulcer is present. 4. There is an area of boggy purple skin on the bony prominence. 5. There is an area of skin that does not turn white with pressure.

2,3

A patient, being treated for burns over 40% of the total body surface area, is experiencing a hypermetabolic state. The nurse anticipates the addition of which type of medication to help reduce muscle wasting and accelerate healing time? 1. Antibiotics 2. Cardiac glycosides 3. Insulin 4. Calcium channel blockers

3

Victims of a house fire are being admitted through the emergency department.Of the patients, the nurse realizes that which will have the greatest general risk for mortality from the burn injuries ? 1)25-year-old pregnant female 2) 49 - year - 1 old male who smokes 3) 75-year -old female with arthritis 4 )50- year -old male with coronary artery disease 3

3

lavage treatments for a chronic ulcer on the left heel. Which explanation would the nurse provide for this treatment? 1. "This treatment is a form of autolytic debridement to remove dead tissue from your heel." 2. "Your foot will be submersed in a whirlpool tub for this treatment." 3. "This treatment will help cleanse the wound bed." 4. "This treatment will inject medications into the deep crevices of your wound."

3

The nurse is planning the care of a patient who has burns to the face, neck, upper chest, and both upper arms. To prevent contracture development, the nurse should include which interventions in the patient's plan of care? Select all that apply. 1. Use a bed cradle over the burned areas. 2. Have patient assume the position of comfort while sleeping. 3. Administer analgesics prior to physical therapy. 4. Instruct the patient to avoid using pillows under the head. 5. Get the patient out of bed as soon as medically feasible

3,4,5

. 14. Which information obtained by the nurse when caring for a patient who has cardiogenicshock indicates that the patient may be developing multiple organ dysfunction syndrome(MODS)? a. The patient's serum creatinine level is elevated .b. The patient complains of intermittent chest pressure .c. The patient has crackles throughout both lung fields. d. The patient's extremities are cool and pulses are weak.

A

29. A patient with advanced venous insufficiency is confined following orthopedic surgery. How can thenurse best prevent skin breakdown in the patients lower extremities? A) Ensure that the patients heels are protected and supported. B) Closely monitor the patients serum albumin and prealbumin levels. C) Perform gentle massage of the patients lower legs, as tolerated. D) Perform passive range-of-motion exercises once per shift

A

78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? a. Give PRN furosemide (Lasix) 40 mg IV .b. Increase normal saline infusion to 250 mL/hr. c. Administer hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.

A

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? a) 27% b) 45% c) 18% d) 36%

A

A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm a) Full-thickness b) Deep partial-thickness c) Superficial partial-thickness D) Full partial-thickness

A

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments b. repositioning the patient every 2 hours c. performing active ROM at least every 4 hours d. massaging the new tissue with water-based moisturizers

A

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? a) 36% b) 27% c) 18% d) 9%

A

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

A

patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.

A

Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient's central venous pressure is 3 mm Hg. b. The patient is in sinus tachycardia at 120 beats/min .c. The patient is receiving low dose dopamine (Intropin). d. The patient has had no urine output since being admitted.

A Low CVP= need more fluid before Norepinephrine

The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply .a) Urine output b) Blood pressure c) Heart rate d) Oxygen saturation

A B C

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. a) Facial burns b) Bradypnea c) Singed nasal hair d) Yellow sputum e) Hoarseness

A C E

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a.Additional pain medication may be needed because of rapid body metabolism. b.Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c.Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d.The intramuscular route is preferred for pain medication administration.

A,B,C

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery .c. Remove indwelling urinary catheters as soon as possible after surgery. d. Advocate for parenteral nutrition for patients who cannot take oral feedings. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis

A,B,C,E

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a.Applying splints that maintain the extremity in an extended position b.Implementing passive or active range-of-motion exercises c.Keeping the limbs as immobile as possible d.Wrapping fingers and toes individually with bandages

A,B,D

Which complications may manifest after an electrical injury? (Select all that apply.) a.Long bone fractures b.Cardiac dysrhythmias c.Hypertension d.Compartment syndrome of extremities e.Dark brown urine f.Peptic ulcer disease g.Acute cataract formation h.Seizures

A,B,D,E,G,H

Pain management for the burn patient is most effective when Select all that apply a. a pain rating tool is used to monitor the patient's level of pain b. painful dressing changes are delayed until the patient's pain is completely relieved c. the patient is informed about and has some control over the management of the pain d. a multimodal approach is used (short-acting opioids, NSAIDs, adjuvant analgesics) e. nonpharmacologic therapies replace opioids in the rehabilitation phase of a burn injury

A,C,D

When assessing a patient with a partial-thickness burn, the nurse would expect to find Select all that apply a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance

A,D,E

32. A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower legpain. On inspection, the nurse observes that the patients left leg is visibly swollen and reddened. What isthe nurses most appropriate action? A) Administer a PRN dose of subcutaneous heparin .B) Inform the physician that the patient has signs and symptoms of VTE.. C) Mobilize the patient promptly to dislodge any thrombi in the patients lower leg. D) Massage the patients lower leg to temporarily restore venous return

B

A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126,respirations 30. The PAWP is increased and cardiac output is low. The nurse willanticipate a. infusion of 5% human albumin. b. administration of furosemide (Lasix) IV. c. titration of an epinephrine (Adrenalin) drip. d. administration of hydrocortisone (SoluCortef).

B

A patient with respiratory failure has a respiratory rate of 6 and (SpO 2 ) of 88 %. The patient is increasingly lethargic . Which intervention will the nurse anticipate ? A.Administration of 100% O2 by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c.Insertion of a mini- tracheostomy with frequent suctioning d. Initiation of ( CPAP)

B

After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58

B

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. nitroglycerine (Tridil) .b. norepinephrine (Levophed). c. sodium nitroprusside (Nipride). d. methylprednisolone (Solu-Medrol).

B

Nutritional support of the burned individual is designed to A) limit the glucose available to infectious organisms . B) create a positive nitrogen balance. C ) protect the kidney from excessive protein intake . D) avoid hyperlipidemia .

B

When caring for a patient who has septic shock, which assessment finding is mostimportant for the nurse to report to the health care provider? a. BP 92/56 mm Hg b. Skin cool and clammy c. Apical pulse 118 beats/min d. Arterial oxygen saturation 91%

B

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? a) To prevent collapse and further injuries B) To keep fire and smoke from airway c) To promote blood flow to the brain and vital organs d) To distinguish flames more quickly

B

While caring for a patient who has been admitted with a pulmonary embolism , the nurse notes a change in the patient's oxygen saturation ( SpO2 ) from 94 % to 88\% Which action should the nurse take ? a.Suction the patient's oropharynx . b.Increase the prescribed O 2 flow rate . c. Instruct the patient to cough and deep breathe . d. Help the patient to sit in a more upright position .

B

While the patient's full -thickness burn wounds to the face are exposed , what is the best nursing action to prevent crosse sehing contamination ? A ) Use sterile gloves when removing old dressings . B ) Wear gowns , caps , masks , and gloves during all care of the patient C ) Administer IV antibiotics to prevent bacterial colonization of wounds . D ) Turn the room temperature up to at least 70 degrees * (20 degrees * C) during dressing changes

B

Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation? a) Hands, major joints b) Face, neck, chest c) All options are correct. d) Perineal

B

patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief between dressing changes d. wash the wound aggressively with soap and water 3 times a day

B

A 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of: a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.

B Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion

Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) a.Burn injury less than 10% b.Bedrest c.Burns to lower extremities d.Electrical burn injury e.Delayed fluid resuscitation

B,C,E

1st priority when rescuing burns pt is A. Establish patent airway B. remove clothing C. eliminating sources of burn D. Cover wounds with wet sheets

C

2nd degree, superficial, partial thickness burns a. Less painful than 3rd degree burns b. Involves only epidermis c. Heals in 7-21 days d. rarely associate with scars formation

C

A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that hisproblems first began when he stubbed his toe going to the bathroom in the dark. In addition to thistrauma, the nurse should suspect that the patient has a history of what health problem? A) Raynauds phenomenon B) CAD C) Arterial insufficiency D) Varicose veins

C

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? a) Superficial partial-thickness b) Deep partial-thickness c) Full-thickness d) Superficial

C

A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? a) High fever b) Sudden agitation c) Decreased blood pressure d) Confusion

C

After receiving 1000 mL of normal saline, the central venous pressure for a patient whohas septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nursewill anticipate the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride

C

Burns covering 25 % to 35 % of the total body surface area A ) are often associated with burn shock . B) can rarely be grafted . C) are nearly always fatal D) are classified as major burns in children but not in adults

C

Dry, rough, scaly skin with the presence of itching is best described as: a) Candidiasis b) Seborrhea c) Pruritus d) Shingles

C

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls b. movement of potassium into the vascular space c. sequestering of sodium and water in interstitial fluid d. hemolysis of RBC from large volumes of rapidly administered fluid

C

The most common cause of burn injuries in children is A) house fires . B) cigarette bums . C) scalding with hot water . D ) contact with chemical agents .

C

The spouse of a victim, who was struck by lightning, asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? A) Lightning is higher in voltage than electricity. b) Moisture intensifies the damage inflicted. c) Electrical burns usually follow an internal path. d) The skin is a good conductor of electricity.

C

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. Mannitol 75 g IV b. Urine for myoglobulin c. Lactated Ringer's solution at 25 mL/hr d. Sodium bicarbonate 24 mEq every 4 hours

C

Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure ? A. Chest x - ray B. O2 saturation C. ABG analysis D Central venous pressure monitoring

C

Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient's heart rate is 110 beats/minute .c. The patient is complaining of chest pain. d. The patient's peripheral pulses are weak.

C

Which of the following is the analgesic of choice for burn pain? A) Tylenol with codeine b) Demerol c) Morphine sulfate d) Fentanyl

C

Within the burn unit, you must be continually aware that clients may develop potential complications based on the type of burn they endured. Which burns have a common complication of cardiac dysrhythmias? A) Heat B) Thermal C) Electrical D) Chemical

C

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? a) Superficial partial-thickness b) Full-thickness c) Deep partial-thickness d) Superficial

D

An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?a) Administer IV potassium chlorideb) Administer packed red blood cellsc) Administer broad-spectrum antibioticsd) Administer IV fluids Administer IV fluids The nurse is providing care for a patent with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the patient is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. The nurse's best response based on the clinical findings is which of the following? a) Apply an elastic stocking to the extremity and administer SQ heparin per order. b) Document the findings and instruct the patient to report numbness of the extremity. C) Elevate the leg on pillows and reassess the leg in 1 hour. d) Contact the primary care provider and prepare for an escharotomy.

D

An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A) Use of supplementary oxygen to aid tissue oxygenation B) Daily use of normal saline compresses on the lower limbs C) Daily administration of prophylactic antibiotics D) A high-protein diet that is rich in vitamins

D

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature .c. pulse pressure, level of consciousness, and pupillary response. d. LOC, urine output, and skin color and temperature.

D

The primary aim of burn wound management is to A) prevent trauma to burned tissue. B) prevent microbial colonization of the wound. C) keep the wound dry D) prevent premature wound closure

D

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? a) Complaints of intense thirst b) Moderate to severe pain c) Urine output of 70 ml the first hour D) Hoarseness of the voice

D

. 1. The health care provider prescribes these actions for a patient who has possible septicshock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will thenurse implement the actions? Put a comma and space between each answer choice (a, b,c, d, etc.) ___________________ _a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV .c. Infuse vasopressin (Pitressin) 0.01 units/min .d. Administer normal saline 1000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.

E,D,C,A,B