U4
Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?
"The medication is likely to cause stinging every time it is applied."
The health care provider has determined that a client has irreversible brain damage with subsequent brain death. Organ donation is discussed with the family. Which action should the nurse take prior to contacting the organ procurement organization (OPO)?
. Obtain informed consent.
A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment?
100% humidified oxygen by face mask
A client sustained a burn injury at 7:00 a.m. The client's spouse states befor the burn, the client's body weight was 198 lbs. The primary health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4mL x kilograms of body mass x percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank. (Whole number, no comma.)
14,940mL
A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition?
Hypoxia
A client is undergoing fluid replacement after being burned on 20% of the body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg a pulse rate of 110 beats/minute and a urine output of 20 mL over the past hour. The nurse reports the finding to the primary health care provider (PHCP) and anticipates which prescription?
Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour
A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is the most appropriate?
Keep the client on NPO (nothing by mouth) status
A client sustained a burn form cutaneous expose to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing?
Liquefaction necrosis
The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item?
Lung sounds
The patient has been admitted with a flail chest. Which findings would the nurse expect to observe supporting this diagnoses?
Paradoxical respiratory movement
A patient has sustained a burn related to spilling a cup of hot liquid onto the right hand. Symptoms include skin that is bright red and mottled at the affected area with a vest and weeping appearance and diffuse blister formation. The burned area is excruciatingly painful and sensitive to air current. What is the appropriate classification for this burn?
Partial thickness
A client with multiple injuries is brought to the emergency department by ambulance. The client has had his airway stabilized and is breathing on their own. This nurse does not see active bleeding, but should suspect internal hemorrhage based on what finding?
Rapid pulse and decreased capillary refill
Use the START method to triage the wounded in the following disaster situation: The wounded victim is unable to walk, has respiratory rate of 40, capillary refill of 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color?
Red
The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees what which is the first consideration in immediate care?
Removing all clothing, including gloves and shoes
An older patient with sepsis secondary to urinary tract infection (UTI) has a history of hypertension and congestive heart failure. Medications include an angiotensin-converting enzyme (ACE) inhibitor and beta-blocker, plus valium as needed for anxiety. Which action does the nurse take first if the patient becomes agitated and attempts to remove the foley catheter?
Secure the foley catheter
Which observation would indicate that a patient has an obstructed airway?
Stridor
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
Train-of-four yields two twitches
The nurse is assessing a client who is admitted with a wound caused by gunshot trauma. What information will help the nurse predict the amount of damage?
Type of weapon and caliber of bullet
An elderly patient is admitted to the critical care unit with a fractured pelvis after falling at home. It is not known how long the patient laid on the floor before being discovered. The patient is disoriented, complaining of pain and moaning; pulse is 100 and weak; respiratory rate is 24 and shallow; and pain presents on palpation of the abdomen. Which assessment is priority?
Urinalysis
The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?
Urine specific gravity of 1.032
The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest are from a fire. Which assessment finding would indicate that the chest sustained a respiratory injury as a result of the burn?
Use of accessory muscles for breathing
An adult patient weighing 60 kg has sustained a major burn injury to 50% of the total body surface area (TBSA). Which action would the nurse perform first when following the Parkland fluid resuscitation formula during the first 24 hours?
Administer LR solution at a rate of 750 mL/h during the first 8 hours
An elderly client in the ICY is receiving sulfate 25 mg/h via continuous infusion after undergoing a left hip arthroplasty. On routine assessment the nurse notes the following: respiratory rate 8 breaths/minute; blood pressure 110/68 mm Hg; heart rate 79 beats per minute; otic (tympanic) temperature 98.8°F; SpO2 90%; lethargy; capillary refill of 4 seconds in both hands and right toes and 6 seconds on the left toes. Identify the nursing priority.
Administer naloxone
The nurse is admitting a client who has been exposed to the botulism toxin during a terrorist attack. What should the nurse include in the client's immediate interdisciplinary care? Select all that apply.
Administration of antitoxin Respiratory support
A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.)
Administration of sedatives concurrently with neuromuscular blockade. Ensuring that deep vein thrombosis prophylaxis is initiated. Providing interventions for eye care, oral care, and skin care.
A client is brought to the emergency department with partial-thickness burns to the face, neck, arms, and chest after trying to put out a care time. The nurse needs to implement which nursing actions for this client? Select all that apply.
Assess for airway patency. Administer oxygen as prescribed. Elevate extremities if no fractures are present.
The primary survey of a trauma victim in the emergency department reveals the patient is awake and tachypneic, is using accessory muscles of respiration, has unequal chest expansion, and is very anxious. There are absent breath sounds on the right and cyanosis on 100% oxygen and, the trachea is deviated to the left. Identify the nursing priority.
Chest tube insertion
A nurse is caring for a patient who suffered a fall from a ladder and a subsequent Grade II hip and femur fracture. The patient had surgery to repair it and is currently in a cast. On assessment, the nurse notes pallor and paresthesia, and the patient reports increasing pain despite pain medications or elevation. The nurse is concerned for which possible complication?
Compartment syndrome
Which intervention would the nurse expect the emergency medical services (EMS) staff to have performed in the field for a patient with a spinal cord injury? Select all that apply.
Control of bleeding or hemorrhage Ventilation and breathing assistance Spine immobilization Establishment of IV access Airway management
A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication?
Dark tea-colored urine Decreased urine output Increased serum creatine kinase level
Which statements concerning licensure as a registered nurse are correct? Select all that apply?
Each nurse practice act describes requirements for initial licensure Candidates for licensure must present proof of graduation as required by the state
The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse develops a postoperative plan of care for the client and should include which intervention in the plan?
Elevate and immobilize the grafted extremity
The nurse is developing a plan of care for a client who sustained an inhalation burn injury. Which nursing intervention would the nurse include in the plan of care for this client?
Elevate the head of the bed.
The nurse is caring for a client who is demonstrating signs of impending death. The family is experiencing emotional distress as the client's condition declines. Which information should the nurse provide the family to facilitate the process?
Encourage the family to give the client permission to die.
The nurse provider cares for a patient with carbon monoxide poisoning. The nurse expects what assessment findings. SATA
dyspnea confusion
The nurse is evaluating fluid resuscitation attempts in a burn client. Which finding indicates adequate fluid resuscitation?
heart rate of 95 beats/min
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?
return of distal pulses
You are assessing a patient who was involved in a motor vehicle accident. You notice bruising around her umbilicus. Which of the following clinical manifestations would be consistent with an injury to the liver?
right upper quadrant pain, hypotension, hematuria
In a patient with a head trauma. Battle sign is indicative of which type of injury?
skull fracture
An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?
36%
Which score on the Critical Care Plan Observation Tool (CPOT) indicates that the patient needs to receive pain medication?
8
Which question would be the nurse's priority to ask when caring for a trauma patient who has a positive drug toxicology screen?
?
The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention would the nurse include in the plan of care?
Monitor mental status every hour.
The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action?
Monitor the radial pulse every hour.
A client sustained an injury to the right arm after falling off a motorcycle and is complaining of severe pain and unable to feel the fingers of the right hand. Radial pulse is absent. Identify the nursing priority.
Notify the physician.
Which information is used to classify mass casualty events? Select all that apply.
Number of victims Extent of resources needed
Which finding would suggest the need for a neurological exam?
Posturing
Which action would the nurse take to manage acute pain for a patient with a major burn injury? Select all that apply. One, some or all responses may be correct.
Provide analgesic medication before dressing changes Monitor pain scale for improvement of pain control Use guided imagery as an adjunct to drug therapy Allow patient control over their pain treatment options
A patient had been brought to the emergency department via ambulance with resuscitation efforts being performed. It is unlikely that the patient will survive injuries sustained. Two adult children of the patient are present and are requesting to be with the patient at this time. What is the best response by the nurse?
You may come in with your parent and I will have someone stay with you to explain what is happening."
The patient who sustained blunt chest injury is admitted to your unit. The patient develops dyspnea and confusion and has distant heart tones. Two hours post admission the BP has changed from 140/78 to 92/78. The patient now has visible jugular venous distention. The most likely cause is:
cardiac tamponade
