questions from chapters 8 10 and 26 for test 4.
28 year old male pt. sustained 2 and 3 dree burns on his legs (30%) when his clothing caught fire while he was burning leaves. He was hosed down by his neighbor and has arrive at the ED in severe discomfort. what is the priority problem for this pt at this time. 1. acute pain related to damaged or exposed nerve endings 2. decreased fluid volume related to electrolyte imbalance 3. potential for inadequate oxygenation 4. diminished self inmate related to the appearance of legs
1
The nurse serves on a committee that is tasked to develop tools and aids that the medical command physician could use during a disaster event. what is an appropriate project for this purpose 1. make a current list, including contact information, trauma. and orthopedic surgeons. 2. make a telephone tree for contacting nursing nd ancillary staff. 3. design a triage algorithm that address different types of disaster events 4. design an algorithm for contacting the federal emergency management agency.
1
a pt in the burn intensive care unit is recieving vecuronium. what is the priority nursing intervention for this pt. 1. have emergency equipment at the bedside 2. ensure that all the equipment alarms are on and functional 3. closely monitor the patients urinary output every hour 4. ensure that daily drug levels and electrolyte values are obtained
2
which feeling are most typically expressed by the burn patient? 1. suspicion 2. regression 3. Apathy 4. Denail 5. Suicidal ideations 6. Anger
2 4 6
a pt has sustained a relatively large burn. the nurse anticipates the the pt. nutritional requirements may exceed how many kcal/ day. 1. 1500 2. 2000 3. 3000 4. 5000
4
Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? Pale, boggy, dry, or crusted granulation tissue Increasing wound drainage Scar tissue formation 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.
a gang related incident has occurred involving a major casualties from gunshot wounds to 11 victims. Which type of debriefing is utilized buy the hospital after handling this event. 1. critical stress incident 2. posttraumatic stress 3. administrative stress 4. restoring normalcy
1
a pt has sustained a burn to the rt ankle. the provider has applied the initial dressing o the ankle and he nurse assists the pt into the bed and positions tb ankle to prevent contracture. What is the correct placement of the ankle ? 1. dorsiflexion 2. adduction 3. external rotation 4. hyperextension
1
a pt was burned on the forearm after tripping and falling against a wood burning stove. there are currently several small liters over the burn area. What does the nurse advise the patient to do about the blisters. 1. leave the blisters intact because they protect the wound from infection 2. use a sterile needle to open a tiny hole in each blister to drain the fluid 3. allow blisters to increase in size then open them to prevent immunosuppression 4. leave the blisters intact unless the pain and pressure increase.
1
the nurse is applying a dressing to cover a burn on a pts left leg. what technique does the nurse use? 1. consider the depth of the injury and amount of drainage, and work distal to proximal. 2. change the dressing q4 or when the drainage leaks through the dressing 3. consider the pts mobility and the area of injury and work proximal to distal 4. use multi gause layers and roller gauze to pad and protect the joint areas.
1
a burn pt in the fluid resuscitation phase is experiencing dyspnea. what are the priority interventions for this pt. (select all that apply) 1. elevate the head of bed to 45 degrees. 2. maintain pt in the supine position 3. notify the rapid Response team 4. administer an analgesic to clam the patient 5. apply humidified oxygen
135
Pt brought to ED because of being verbally abusive and threatening others and attempted to stab the neighbors dog. what does the nurse do to ensure safety of the t and others. 1. search pt belongings and secure personal effects 2. remove dangerous equipment from room, such as sharps containers or portable things 3. instruct pt family to stay with him and call for help as necessary 4. escort the pt to the waiting area where he can be readily observed by the triage nurse 5. use a metal detector to search for objects that could be used to cause harm 6. instruct nursing students to aviod wearing a stethoscope around their necks
1356
The nurse has just recieved a phone report on a burn pt being transferred from the burn ICU to the Step down unit. which of these task are appropriate to delegate to UAP in order to prepare the room. 1.Place sterile sheets and a sterile pillowcase on the bed 2. place a new disposable stethscope in the room 3. clear a space in the corner for flowers 4. hang a sing on the door to prohibit entry of vistiros
2
Which ED pt represents an issue that has been addressed by the core measures sets for the ED that are established by the joint commission. 1. pt has no health insurance and no steady income 2. pt has waited for 7 hours to be transferred to the medical surgical unit 3. pt has a hist of falls and sustains a fall in the ed waiting room. 4. pt has resp arrest and requires emergency intubation
2
a pt comes to the ED with severe respiration distress. he has long history of chronic respiratory disease and now requires trach intubation. how does the nurse assess this pt lung compliance. 1. auscultate the lung fields. especially for corase crackles. 2. sense the degree of difficulty in ventilating with a BVM 3. monitor the 02 for desceasing stat 4. count the resp rate and observe the respiratory effort.
2
nurse is caring for a young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. which lab results does the nurse expect to see during the resuscitation phase. 1. k level of 3.2 2. glucose level of 180 3. hematocrit of 49% 4. ph 7.2 5. NA level of 139
3 4
A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the client's oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the client's intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.
ANS: B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.
After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Vital Signs Laboratory Results Wound Assessment Heart rate: 110 beats/min Blood pressure: 112/68 mm Hg Respiratory rate: 20 breaths/min Oxygen saturation: 94% Pain: 3/10 Red blood cell count: 5,000,000/mm3 White blood cell count: 10,000/mm3 Platelet count: 200,000/mm3 Left chest burn wound, 3 cm ´ 2.5 cm ´ 0.5 cm, wound bed pale, surrounding tissues with edema present Based on the documented data, which action should the nurse take next? a. Assess the client's skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.
ANS: C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the client's skin should all be implemented but these actions do not take priority over determining whether the client has an infection.
nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this client's discharge teaching? a. "You should change the batteries in your smoke detector once a year." b. "Join a program that assists burn clients to reintegration into the community." c. "I will demonstrate how to change your wound dressing for you and your family." d. "Let me tell you about the many options available to you for reconstructive surgery."
ANS: C Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.
the nurse is interviewing a homeless pt in the triage are. the pt says Im a nurse too. flying pistes say god is me. and all other kinds of shit. the pt kicks over the trash can . what should the nurse do first 1. remain calm and slowly step away from the pt. 2. run towards the panic button 3. gently take the pt arm and lead her to a quiet space 4. call for help and instruct bystanders to get out of the way.
1
the nurse is reviewing the lab results for several burn pt who are approximately 24 to 36 hours post injury. What laboratory results related to the fluid remobilization in these patients does the nurse expect to see? 1. anemia 2. metabolic alkalosis 3. hypernatremia 4. hyperkalemia
1
the nurse sees that the emergency provider has written an order to discharge an elderly pt to go home. the pt cannot walk independently and has no relatives. what should the nurse do first 1. talk to provider about the pt self care abilities 2. ask the pt if a friend could come to the hospital 3. obtain a taxicab voucher for the pt. 4. consult social services for nursing home placement
1
the provider has ordered an eschartomoy for a pt because of constriction around the pt chest. the nurse is teaching the pt and family about the procedure. which statement by the family indicates a need for additional teaching 1. he doesn't do well under general anesthesia 2. he will be awake for the procedure 3. he will receive medication for sedation 4. we could stay with him at the bedside during the procedure
1
what is the fastest way for the nurse to estimate systolic BP in a pt with multi injury. 1. palpate for preside of radial pulse 2. use automatic BP cuff 3. place pt on monitor 4. check for cap refill
1
which nurse activity would best help the hospital meet the joint commission mandate for emergency preparedness. 1. assist in planning drills that include patient simulations. 2. help other nurses make a personal emergency preparedness plan. 3. attend training classes to learn how to handle hazardous materials. 4. identify the credible threats to safety of the community.
1
a pt comes to the clinic to be treated for burns form a bbq fire. although the patient does not appear to be in any resp. distress, the nurse suspects an inhalation injury after observing which findings? 1. burns to the face 2. bright cherry red color to lips 3. signed nose hairs 4. edema of the nasal septum 5. black carbon particles around the mouth 6. sweet, sugary smell to the breath
1 3 4 5
the nurse is monitoring the nutritional status of a burn pt. Which indicators will the nurse use? 1. amount of food the pt eats 2. weight to height ratio 3. serum albumin 4. amount of water pt drinks 5. blood glucose 5. serum K
1235
to protect hospital staff from experiencing PTSD, what are appropriate recommendateions by the facility to its employees 1. drink lots of water 2. limit verbalizing feelings to family friends 3. use available counseling 4. encourage and support coworkers 5. do not work more than 14 hours
134
at 3 am the ED charge nurse of a large subran hospital receives notiation that a commercial plane has just crashed outside the city limits. what does the nurse do 1. collaborate with the medical command physician 2. activate the hospitals emergency management plan 3. initiate the staff telephone tree 4. collaborate with the triage officer 5. organize nursing and ancillary services
1345
The hospital in a small mountain town is updating their emergency management plan to incorporate the all ahzards approach and to address all credible threats to the are. which disaster events are the likely priorities in this communities emergency management plan. 1. avalanches 2. floods 3. burns 4. car accidents 5. tornadoes 6. bioterrorism.
1346
The student nurse is preparing to assist with hydrotherapy for a burn pt. the supervisoring nurse instructs the student to obtain the necessary equipment before beginning the procedure. what equipment does the student nurse obtain? 1. sissors and forceps 2. hydrogen peroxide 3. mild soap or detergent 4.pressure dressings 5. washcloths and gauze sponges 6. chlorhexidine sponges
135
a pt is transported to the ED for severe and extensive burns tat occurred while he was trapped in a burning building. the pt is severely injured with resp distress and the resuscitation team must immediately begin multiple interventions. Which task is delegated to the UAP. 1. position the pt head to open the air way and assist the intubation 2. assist the resp therapist to maintain a seal during BVM ventilation 3. prepare the intubation equipment and set up the 02 flowmeter 4. elevate the head of the bed to achieve a high fowler position.
2
wich function represents an appropriate referral to the case manager. 1. check with admissions office to get a count of available intensive care beds. 2. contact the PICC nurse, because the pt has bad veins. 3. investigate whether the pt is abusing and overseeing ed services 4. follow the pt into the community setting and evaluate the home environment .
3
each patient listed below has entered the meds waiting area. place them in order of priority. 1. 3 year old child with inconsolable high pitched crying, fever, headache, and nuchal rigidity 2. 65 year old man having diaphoreses with left anterior crushing chest pain 3. 32 year old woman reporting upper abdominal pain and vomiting green bile emesis 4. 16 year old boy with a broken arm from skate boarding and has a pulse in the arm
2134 in that order of severity
The nurses next door neighbor has sustained a deep laceration to the right upper arm and there is active bright red bleeding what does the nurse do to immediately control the bleeding. 1. apply a tourniquet just above the laceration 2. have a neighbor lie flat and elevate the arm 3. apply direct pressure with a thick dry towel. 4. apply sterile gauze and wrap the wound with an ace bandage 5. rinse the wound gently with tepid water and apply direct pressure with towel.
23
which criterion describes a full thickness burn wound. 1. the wound is red and moist and blanches easily 2. there is destruction to the epidermis 3. there are no skin cells for regrowth 4. the burned tissue is avascular 5. the burn wound will not be painful
234
the home health nurse is visiting an older couple for the initial list. in observing the house hold, the nurse identifies several behaviors and environmental factors to address. Which identified factors increase the risk for burns and or household fires. 1. a several potholders hanging within easy reach of the stove 2. ashtray with old cigarette butts on the bedside table 3. space heater very close to the bed 4. single smoke detector in the kitchen 5. back hall of the house used as a storage space.
2345
ED nurse is caring for several pt. all of whom are currently lying on stretchers either pending discharge or awaiting transfer to a hospital bed. which patients have the greater risk for falls. 1. pt with chronic pain who received 10 mg PO oxy for myalgia 2. opioid naive teenager with a fracture who received 3 mg Iv morphine for pain 3. Middle aged woman with severe vomiting and frequent watery stools for 3 days. 4. child with fever of 102 crying with an ear infection 5. older adult pt with acute dementia secondary to infection
235
A burn pt with which condition is most likely to have mannitol ordered as part of the drug therapy. 1. peripheral edema associated with burns on the lower extremities 2. inhalation Burns around the mouth causing mucosal swelling 3. electrical burn and myoglobin in the urine 4. smoke inhalation and superficial burns to the forearms
3
The nurse is evaluating the lower extremities of several pt. which description represents the least serious physical presentation 1. pain in calf lower leg is swollen and red 2. progressively increasing pain; distal portion is cool and bluish 3. decreased sensation. lower leg has widen spread brownish discoloration 4. tight senstatoin in ankle; skin appears tight, shiy and edematous.
3
Trauma team is preparing to recieve a motor vehicle crash victim with severe chest trauma with coughing of blood and a crush injury to the right leg. what type of personal protective equipment does the nurse assigned to be the recorder need? 1. NO PPE 2. gloves 3. gown gloves, eye protection face mask cap and shoe covers 4. the pt situation must first be assessed before situation must first be assessed before determining what PPE to wear
3
Which typer of burn destroys the sweat glands resulting in decreased excretory ability 1. superficial 2. partial thickness 3. full thickness 4. deep full thickness
3
at what pint does fluid mobilization occur in pt with burns. 1. after the scar tissue is formed and fluids are no longer being lost 2. within the first 4 hours after the burns were sustained 3. after 36 hours when the fluid is reabsorbed form the interstitial tissue 4. immediately after the burns occur
3
the ed nurse is attempting to transfer a pt to the medical surgical unit. when the receiving nurse answers the phone, he says you people always dump these admit on us during shift change. which is the best response by the ed nurse. 1. i am sorry. i realize you are busy but we are busy too. 2. when would you be will to take our pt. 3. i apologize for the timing. I will call back in 30 minutes 4. I apologize. We just received the bed assignment.
3
the nurse observes that a homeless woman frequently comes tot the ED. during the winter for symptoms of dizziness and gerneralized pain. the pt typically stays for several hours, undergoes diagnostic testing and is discharged with a referral to a primary care provider. what should the nurse do. 1. assess and treat the pt as if she were any other pt. 2. offer food and a blanket and encourage her to leave after she warms up 3. develop an individual care plan using interdisciplinary team approach 4. talk to the pt and attempt to establish validity of symptoms
3
which statement about the resuscitation phase of a burn injury is accurate. 1. it occurs in the prehospital time frame 2. it continues for about 4 hours after the burn 3. it continues for about 48 hours after the burn 4. it continues until the pt is stable.
3
whicih drug therapy reduces the risk of wound infection for burn pt. 1. large dose of oral anti fungal medications q4 2. silver nitrate solution covered by dry dressings applied every 4 hours 3. silver sulfadiazine silvadene on full thickness injuries q 4 4. broad septum antibiotics given IV
3
the nurse is caring for a burn pt about to undergo hydrotherapy. which complementary therapies are appropriate for pain management in this pt. 1. administration of IV opioid analgesics 2. allowing the pt. to make decisions regarding pain control 3. playing music in the background 4. use of mediative breathing 5. use of guided imagery.
345
a pt has severe burns to the anterior surface of the body from a short exposure to high temp at a worksite furnace. which area of the body is most vulnerable to a deep burn injury. 1. anterior chest 2. upper arms 3. palmar surface hands 4. eyelids
4
pt is brought to the ED by friends who report he probably OD on downers. the pt has decreased LOC and decreased gag reflex. his face and chest are covered with emeisi. he demonstrates spontaneous sonorous resp and 02 of 87%. what type of airway management does the nurse expect this pt to receive. 1. 02 per nasal cannual at 4-6 liters per minute 2. BVM and 100% o2 to assist with ventilatory effort. 3. Nonrebreather mask with high flow o2 4. endotracheal intubation with initial high concentration 02
4
what method does the nurse use to correctly weigh this pt. 1. weigh once a week after morning hygiene and compare to previous weight 2. weigh daily at the same time of day and compare to pre burn weight 3. use a bed scale and subtract the estimated weight of linens 4. weigh daily without dressings or splints and compare to pre burn weight
4
Mass casualties has occurred near an urban hospital. the hospital emergency preparedness plan is activated. for what purposes is the post plan administrative review conducted 1. to identify only the things that went wrong 2. to identify employees who need money assistance or reimbursement 3. to establish a social networking system for the employees the opportunity to express positive and negative feelings 4. to solicit written critique forms for addition information .
45
newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? Painful red and white wounds Painless, brownish yellow eschar Painful reddened blisters Painless black skin with eschar
A A 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.
A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? Encouraging participation in wound care Encouraging visitors Reassuring the client that he or she will be fine 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.
To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? In a neutral position In a position of comfort Slightly flexed 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.
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? "Every bedroom should have a separate smoke detector." "Every room in the house should have a smoke detector." "If you have a smoke detector, you don't need a carbon monoxide detector." "The kitchen and the bedrooms are the only rooms that need smoke detectors."
A Teach all people to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home. Recommendations are that each bedroom has a separate smoke detector, there should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Carbon monoxide detectors are instrumental in picking up other types of carbon monoxide gas, such as from a defective heating unit.
A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy. ANS: A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.
ANS: A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.
A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time - Increased risk for loss of function from contracture formation b. Reduced inflammatory response - Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance - Increased risk for atelectasis d. High incidence of cardiac impairments - Increased risk for acute kidney injury e. Thinner skin - May not exhibit a fever when infection is present
ANS: A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.
A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.
ANS: A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.
The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.
ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the client's body can prevent autocontamination.
A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.
ANS: B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this client's inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.
A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. "I will allow my spouse to change my dressings." b. "I want to have surgical reconstruction." c. "I will bathe and dress before breakfast." d. "I have secured the pressure dressings as ordered."
ANS: C Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.
The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. "Administer the prescribed tetanus toxoid vaccine." b. "Assess the client's wounds for signs of infection." c. "Encourage the client to breathe deeply every hour." d. "Wash your hands on entering the client's room."
ANS: D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.
A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.
ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.
A school bus overturns in a small, rural community that is served by a critical access hospital and one volunteer fire department. How is the incident of the overturned school bus categorized? Not a mass casualty May be a mass casualty Mass casualty Internal disaster
B A mass casualty event overwhelms local medical capabilities. It may require the collaboration of multiple agencies and health care facilities to handle the crisis. Depending on the community, available resources, and the quantity and severity of those injured, this may be a mass casualty. The overturned school bus will likely require the hospital to activate their disaster plan; however, since it occurred outside of the facility, this would be an external disaster.
As a direct result of overcrowding in emergency department (ED) environments, for whom must the emergency department nurse expect to provide care? A variety of age groups and cultures "Boarding" or holding inpatient clients Clients with a broad spectrum of issues, illnesses, and injuries Uninsured and underinsured clients
B ED overcrowding has become a widespread problem, with frequent boarding or holding of admitted clients in the ED because of lack of beds in the hospital. The ED nurse must be adept at providing safe and competent care to clients who are awaiting bed placement. The focus then becomes one of ongoing care (scheduled medications, testing) instead of one-time orders. Although a variety of age groups and cultures; clients with a broad spectrum of illness, issues, and injuries; and uninsured/underinsured clients are seen in the ED, this is not a result of overcrowding.
In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? Intense pain Potential for inadequate oxygenation Reduced self-image Potential for infection
B 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.
Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? Middle-aged adult who is frantically explaining to the nurse what happened Young adult who suffered burn injuries in a closed space Adult with burns to the extremities 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 emergency department charge nurse is making client assignments and delegating care after a mass casualty event. Which of these clients could be delegated to a nursing assistant? Client who has multiple left rib fractures and reports dyspnea Client who reports severe left anterior chest pain Client who has a femoral fracture with palpable distal pulses Client who is unconscious with massive aortic bleeding from the chest
D The client who is unconscious and has massive aortic bleeding is unlikely to survive and would be "black-tagged" and assigned to a nursing assistant. The client with rib fractures and dyspnea, the client with chest pain, and the client with a femoral fracture with palpable pulses are likely to survive and should be delegated to licensed staff members.
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? Administer a diuretic. Provide a fluid bolus. Recalculate fluid replacement based on time of hospital arrival. 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.
An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a Glasgow Coma Scale score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client? Level I Level II Level III Level IV
a The American College of Surgeons defines a Level I trauma center as a regional resource facility capable of "providing leadership and total care for every aspect of injury, from prevention through rehabilitation." A Level II trauma center may not be able to meet the resource needs of clients who require very complex injury management, such as those in need of advanced surgical care. The primary focus of a Level III trauma center is injury stabilization and client transfer. In a Level IV trauma center, clients are stabilized to the best degree possible before transfer, with the use of available personnel. Resources, including the consistent availability of a physician, may be extremely limited.
Which factors indicate that a client's burn wounds are becoming infected? (Select all that apply.) Dry, crusty granulation tissue Elevated blood pressure Hypoglycemia Edema of the skin around the wound 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.
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.) Provides cushions and rugs for comfort Performs frequent handwashing Places plants in the client's room Performs gloved dressing changes 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.