Burn stuff
Using the modified Brooke formula, calculate the amount of intravenous solution that will be administered in the first 8 hours for a patient with 40% TBSA and weighs 52 kg.
2080ml 260ml/hr
A patient is brought to the emergency department with the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines.
31.5
In order for the nurse to correctly classify a burn injury, which of the following does the nurse need to assess?Select all that apply. a. the depth of the burn b. extent of burns on the body c. the causative agent and the duration of exposure. d. location of burns on the body 5. the time that the burn occurred
a,b,c,d
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours?
600ml/hr
a nurse is caring for a pt who has burns in ear, head, neck and right arm and hand. the nurse should the pt in which position? a. place right arm and hand flexed in a position of comfort b. elevate right arm on pillow and extend fingers c. assist pt to a supine position with small pillow under head d. position pt side-lying with rolled towel under neck
b
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. assess oral b. check k+ level c. place cardiac monitor d. asses for pain at contact points
c
Which patient should the nurse assess first? a. pt with smoke inhalation who has wheezes and altered mental status b. pt. with full thickness legs burns who has dressing change is scheduled c. Pt with Ab burn complaining 8/10 pain d. Pt with 40% TBSA receiving IVF 500ml/hr
a
A 25-year-old patient is admitted with partial-thickness injuries over 20% of the total body surface area involving both lower legs. The nurse would classify this injury as being which of the following? a. a moderate burn b. a minor burn c. a major burn d. a severe burn e. an intermediate burn
a
A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is MOST important to emphasize to an older adult in dealing with the effects of the sunburn? a. increasing fluid intake b. applying mild lotions c. taking mild analgesics d. maintaining warmth e. using sunscreen
a
A nurse sees a patient get struck by lightning during a thunder storm on a golf course. What should be the FIRST action by the nurse a. Check breathing and circulation b. Look for entrance and exit wounds. c. Cover the patient to prevent heat loss. d. Move the patient indoors to a dry place. e. Get the patient up off the ground.
a
A patient has experienced a burn injury. Which of the following interventions by the nurse is of the highest priority at this time? A. determination of the type of burn injury b. determination of the types of home remedies attempted prior to the patient's coming to the hospital c. assessment of past medical history d. determination of body weight e. determination of nutritional status
a
A patient has sustained a partial-thickness injury of 28% of total body surface area (TBSA) and full-thickness injury of 30% or greater of TBSA. How should the nurse classify this burn injury? a. major b. moderate c. minor d. superficial e. intermediate
a
A patient is being evaluated after experiencing severe burns to his torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause for this assessment finding? a. inability of the damaged capillaries to maintain fluids in the cell walls b. reduced vascular permeability at the site of the burned area c. decreased osmotic pressure in the burned tissue d. increased fluids in the extracellular compartment e. the IV fluid being administered too quickly
a
A patient is scheduled for surgery to graft a burn injury on the arm. Which of the following statements should the nurse include when instructing the patient prior to the procedure? a. "You will begin to perform exercises to promote flexibility and reduce contractures after five days." b. "You will need to report any itching, as it might signal infection." c. "Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve success of the procedure." d. "The procedure will be performed in your room." e. "You will need to be in protective isolation for several weeks after the graft is performed."
a
a pt with circumferential burns on both legs develops decrease in dorsalis pedis pulse strength and numbness in toes. what action should the nurse take? a. notify provider b.monitor pulses c. elevate both legs above heart level d. encourage pt flex and extend toes on both feet
a
A patient receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter. When evaluating the patient's intake and output, which of the following should be taken into consideration? a. The amount of urine will be reduced in the first 24-48 hours, and will then increase. b. The amount of urine output will be greatest in the first 24 hours after the burn injury. c. The amount of urine will be reduced during the first eight hours of the burn injury and will then increase as the diuresis begins. d. The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. e. The amount of urine is expected to be decreased for three to five days.
a
A patient recovering from a major burn injury is complaining of pain. Which of the following medications will be most therapeutic to the patient? a. morphine 4 mg IV every 5 minutes b. morphine 10 mg IM ever 3-4 hours c. meperidine 75 mg IM every 3-4 hours d. meperidine 50 mg PO every 3-4 hours e. fentanyl citrate (Duragesic) 75 mcg patch every 3 days
a
A patient who is being treated with topical mafenide acetate for third-degree burns is demonstrating facial and neck edema. The nurse realizes that this patient most likely: a. is developing a hypersensitivity to the medication. b. is reacting positively to the medication. c. needs an increase in dosage of the medication. d. is not responding to the medication.
a
A patient with third-degree burns is being treated with high-volume intravenous fluids and has a urine output of 40 cc per hour. The nurse realizes that this urine output a. is normal for this patient. b. provides evidence that the patient is dehydrated. c. provides evidence that the patient is over-hydrated. d. is indicative of pending renal failure.
a
A patient with third-degree burns is prescribed gastrointestinal medication. The primary action of this drug is which of the following?a. to prevent the onset of a Curling's ulcer b. to treat a preexisting duodenal ulcer c. to ensure adequate peristalsis d. for the antiemetic properties
a
A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the severity of the burn and how long it will take to heal. With which of the following should the nurse respond to this patient? a. The wound is a deep partial-thickness burn, and will take more than three weeks to heal. b. The wound is a partial-thickness burn, and could take up to two weeks to heal. c. The wound is a superficial burn, and will take up to three weeks to heal. d. The wound is a full-thickness burn and will take one to two weeks to heal. e. Wound healing is individualized.
a
A pt has just been dmitted with 40% TBSA burns. to maintain adequate nutrition, nurse should plan to take which action? a. insert feeding tube and initiate enteral feeding b. infuse TPN via central catheter c. encourage an oral intake of 5,000 kcal/day d. admin MV and minerals in IV
a
A pt with burns on arms, legs, and chest, from house fire. what action should nurse take first? a. auscultate lung sounds b. determine extend and depth of burns c. infuse LR d. admin hydromorphone
a
A therapeutic measure used to prevent hypertrophic scarring during rehabilitation phase of burn recover 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 employee spills industrial acid on both arms and legs at work. what is the priority action that the occupational health nurse at the facility take? a. remove non-adherent clothing and watch b. apply alkaline solution to affected area c. Place cool compresses on area of exposure d. cover the affected area with dry, sterile dressings
a
Following surgical debridement, a patient with third-degree burns does not bleed. The nurse realizes that this patient a. will need to have the procedure repeated. b. will no longer need this procedure. c. will need to be premedicated prior to the next procedure. d. should have an escharotomy instead.
a
The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.
a
The family of a patient with third-degree burns wants to know why the "scabs are being cut off" of the patient's leg. What is the most appropriate response by the nurse to this family? a. "The scabs are really old burned tissue and need to be removed to promote healing." b. "I'll ask the doctor to come and talk with you about the treatment plan." c. "The patient asked for the scabs to be removed." d. "The scabs are removed to check for blood flow to the burned area."
a
The injury that is least likely to result in a full-thickness burn is: a. sunburn b. scald injury c. chemical burn d. electrical injury
a
The nurse caring for pt admitted with 30% TBSA assesses u/o has dramatically increased. What action by the nurse would best ensure adequate kidney function? a. continue monitor u/o b. monitor wbc c. assess blisters and edema d. prepare pt for discharge from burns unit
a
The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which of the following laboratory values is the best indicator of a need to adjust the nutritional program? a. glycosuria b. creatine phosphokinase (CPK) c. BUN levels d. hemoglobin e. serum sodium levels
a
The nurse is providing care to a patient with a third-degree burn on his left thigh and left forearm. During wound care, the nurse applies Elase to the burned areas. Which of the following types of wound debridement is this nurse using? a. enzymatic b. mechanical c. surgical d. topical
a
The nurse notes that a patient with third-degree burns is demonstrating a reduction in his serum potassium level. The nurse realizes that this finding is consistent with which of the following? a. the resolution of burn shock b. the onset of burn shock c. the onset of renal failure d. the onset of liver failure
a
To maintain a positive nitrogen balance in a major burn, the patient must: a. eat a high-protein, low-fat, high-carbohydrate diet b. increase normal caloric intake by about three times c. eat at least 1500 calories/day in small, frequent meals d. eat rice and whole wheat for the chemical effect on nitrogen balance.
a
When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the findings? a. These values are normal for the patient's post-burn injury condition. b. The patient is demonstrating manifestations consistent with the onset of an infection. c. The patient is demonstrating manifestations consistent with an electrolyte imbalance. d. The patient is demonstrating manifestations consistent with renal failure. e. The patient is demonstrating manifestations of fluid volume overload.
a
Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. 34yr pt weight loss of 15% from admin and requires enteral feedings b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns
a
A patient comes into the emergency department with a chemical burn from contact with lye. Assessment and treatment of this patient will be based on what knowledge regarding this type of burn? (Select all that apply) a. This is an alkali burn b. This type of burn tends to be deeper. c. This is an acid burn. d. This type of burn will be easier to neutralize. e. This type of burn tends to be more superficial.
a, b
A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which of the following?Select all that apply. a. a superficial partial-thickness burn b. a thermal burn c. a superficial burn d. a deep partial-thickness burn e. a full-thickness burn
a,b
A patient with a burn injury is prescribed silver nitrate. Which of the following nursing interventions should be included for the patient? Select all that apply. a. Monitor daily weight. b. Monitor the serum sodium levels. c. Prepare to change the dressings every two hours. d. Report black skin discolorations. e. Push fluid intake.
a,b
The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who experienced a major burn event on 45% of the body 24 hours ago. Which of the following results would the nurse expect to see?(Select all that apply) a glomerular filtration rate (GFR) reduced b. specific gravity elevated c. creatinine clearance reduced d. BUN reduced e. uric acid decreased
a,b
A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask in determining the possible severity of the burn injury? Select all that apply. a. What type of current was involved? b. How long was the patient in contact with the current? c. How much voltage was involved? d.Where was the patient when the burn occurred? e. What was the point of contact with the current?
a,b,c
A patient is being discharged after treatment for a scald burn that caused a superficial burn over one hand and a superficial partial-thickness burn on several fingers. What should be included in this patient's discharge instructions?(Select all that apply) a. Report any fever to your healthcare provider. b. Report development of purulent drainage to your healthcare provider. c. Use only sterile dressings on the fingers. d. Cleanse the areas every hour with alcohol to prevent infection. e. Apply the topical antimicrobial agent as instructed.
a,b,c
A nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns. Which agents should be included in these instructions?(Select all that apply) a. drain cleaners b. household ammonia c. oven cleaner d. toiler bowl cleaner e. lemon oil furniture polish
a,b,c,d
During the acute phase of burn treatment, important goals of patient care include which of the following?Select all that apply. a. providing for patient comfort b. preventing infection c. providing adequate nutrition for healing to occur d. splinting, positioning, and exercising affected joints e. assessing home maintenance management
a,b,c,d
A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)? A. Singed nasal hair B. Generalized pallor C. Painful swallowing D. Burns on the upper extremities E. History of being involved in a large fire
a,b,c,e
Pain management for the burn patient is most effective when 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 multi-modal approach is used (e.g., sustained-release and short-acting opioids, NSAIDS, adjuvant analgesics). e. non-pharmacological therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury
a,c,d
The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care? (Select all that apply.) A. Escharotomy B. Administration of diuretics C. IV and oral pain medications D. Daily cleansing and debridement E. Application of topical antimicrobial agent
a,c,d,e
When assessing a patient with a partial-thickness burn, the nurse would expect to find: a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance
a,d,e
A patient is admitted to the emergency department with deep partial-thickness burns over 35 % of the body. What IV solution will be started initially? a. warmed lactated Ringer's solution b. dextrose 5% with saline solution c. dextrose 5% with water d. normal saline solution e. 0.45% saline solution
a.
When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. mannitol 75 gm IV b. urine for myoglobulin c. LR at 25 mL/h d. sodium bicarbonate 24 mEq q.4h
c
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? A. The total 24-hour fluid requirement should be administered in the first 8 hours. B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. D. One half of the total. 24hr fluid replacement should be administered in the first 4 hr
b
A patient comes into the clinic to be seen for a burn that appears moist with blisters. The nurse realizes that this patient most likely has experienced which of the following? a. first-degree burn b. superficial second-degree burn c. deep second-degree burn d. third-degree burn
b
A patient has 25% TBSA burned 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 in between dressing changes d. wash the wound aggressively with soap and water three times a day.
b
A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? A. GI distress B. Tachycardia C. Restlessness D. Hypokalemia
b
A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "It is really too early to know how much your life will be changed by the burn." d. "Why do you feel that way? You will be able to adapt as your recovery progresses"
b
During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? A. Begin IV fluid replacement. B. Monitor for signs of complications. C. Assess and manage pain and anxiety. D. Discuss possible reconstructive surgery.
b
When assessing pt who spilled hot oil on right leg and foot, nurse notes skin is dry, pale, hard. Pt states burn is not painful. what term would the nurse use to document burn depth? a. first degree skin destruction b full-thickness skin destruction c.deep partial thickness d.superficial partial thickness
b
Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.
b
a pt admitted to burn unit with burn on head, face, and hands. with wheezes heard but an hour later lungs are decreased and no wheezes are audible. what is the best action for the nurse to take? a. Encourage pt to cough and auscultate lungs again. b. notify provider and prepare for endotracheal intubation c. document results and continue monitoring RR d. reposition pt in high fowlers and reassess breathing sounds
b
while the pt's full thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. use sterile gloves when removing old dressings b. wear gown, glove, mask, caps during all care of patient c. admin IV antibiotics to prevent bacterial colonization of wounds d. turn temp up at least 70 degrees during dressing changes
b
When evaluating the laboratory values of the burn-injured patient, which of the following can be anticipated? a. decreased hemoglobin and elevated hematocrit levels b. elevated hemoglobin and elevated hematocrit levels c. elevated hemoglobin and decreased hematocrit levels d. decreased hemoglobin and decreased hematocrit levels e. hemoglobin and hematocrit levels within normal ranges
b it said a but i thought both are elevated
When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? Select all that apply. A. The exercises are the only way to prevent contractures. B. Active and passive ROM maintain function of body parts. C. ROM will show the patient that movement is still possible. D. Movement facilitates mobilization of leaked exudates back into the vascular bed. E. Active and passive ROM can only be done while the dressings are being changed.
b,c
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands
b.
The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? a. SQ tetanus toxoid B. IV morphine sulfate C. IM hydromorphone (Dilaudid) D. PO oxycodone and acetaminophen (Percocet)
bA patient with third-degree burns is being treated with high-volume intravenous fluids and has a urine output of 40 cc per hour. The nurse realizes that this urine output1. is normal for this patient.2. provides evidence that the patient is dehydrated.3. provides evidence that the patient is over-hydrated.4. is indicative of pending renal failure.
A patient comes into the physician's office after sustaining chemical burns to the left side of his face and right wrist. The nurse realizes that this patient needs to be treated a. in the outpatient ambulatory clinic. b. in the emergency department. c. in a burn center. d. in the doctor's office and then at home.
c
A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? A. 18% B. 22.5% C. 27% D. 36%
c
A patient is recovering from second- and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to: a. arrange a return-to-clinic appointment and prescription for pain medications b. teach the patient and caregiver proper wound care to be performed at home c. review the patient's current health care status and readiness for discharge to home d. give the patient written discharge information and websites for additional information for burn survivors.
c
A patient with third-degree burns to his right arm is scheduled for passive range of motion to the extremity every two hours. Which of the following should the nurse do prior to this exercise session? a. Empty the patient's in-dwelling catheter collection bag. b. Change the patient's bed linens. c. Medicate for pain d. Change the dressing on the burn.
c
A pt arrived ED after electrical burn from exposure to high-voltage current. what is the priority nursing assessment a. oral temp b. Peripheral pulse c. Extremity movement d. Pupil reaction to light.
c
A pt. with 40% TBSA is in acute phase of tx. which snack would be best for the nurse to offer? a. Bananas b. Orange gelatin c. Vanilla shake d. Whole grain bagel
c
An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in her new home? A. Cook for her. B. Stop her from smoking. C. Install tap water anti-scald devices. D. Be sure she uses an open space heater.
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 vascular space c. sequestering of sodium and water in interstitial fluid d. hemolysis of red blood cells from large volumes of rapidly administered fluid
c
Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 140 degrees F b. Use only hardwired smoke detectors c. Encourage regular home fire exit drills d. Never permit older adults to cook unattended
c
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL
c
The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient? A. Replace the blood lost. B. Maintain a neutral pH. C. Maintain fluid balance. D. Replace serum potassium
c
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? A. Sit or lay in the position of comfort. B. Wear a pressure garment for 8 hours each day. C. Refer the patient to a counselor for psychosocial support. D. Use the sun to increase the skin color on the healed areas.
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 gm IV B. Urine for myoglobulin C. Lactated Ringer's at 25 mL/hr D. Sodium bicarbonate 24 mEq every 4 hours
c
a pt with severe burns has crystalloid fluid replacement order using parklan formula. initial volume to be admin. in first 24 hr is 30,000ml. initial rate of admin is 1875ml/hr, after those first 8 hr what rate should the nurse infuse the IV fluids? a. 350ml/hr b. 523ml/hr c. 938ml/hr d. 1250ml/hr
c
on admission to burns unit, pt with 25% TBSA burn had labs of: Hct:58%, Hgb 18.2, K+ 4.9, Na+ 135. what nurse action would be anticipated? a. monitor U/O q 4hr b. continue to monitor labs c. increase IVF rate d. type and crossmatch for blood transfusion
c
A female patient comes into the clinic complaining of nausea and vomiting after spending the weekend at a seaside resort. Which of the following should be the most important assessment for the nurse? a. normal rest and sleep pattern b. typical meal pattern c. if the patient had to change time zones when traveling to the resort d. if the patient has been sunburned
d
A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. obtain vital signs and a STAT ABG b. encourage the patient to cough and auscultate the lungs again c. document the findings and continue to monitor the patient's breathing d. anticipate the need for endotracheal intubation and notify the physician
d
A patient with third-degree burns to her face just learned that she will have extensive scarring once the burn heals. Which of the following nursing diagnoses would be applicable to this patient at this time? a. Potential for Infection b. Fluid Volume Deficit c. Risk for Ineffective Airway Clearance d. Powerlessness
d
A young pt who is in rehab phase after deep partial thickness to face and neck has nursing dx of disturbed body image. what statement by pt indicated that the problem is resolving? a. "im glad my scars are temporary" b. "I will avoid using a pillow, so my neck will be ok" c. "I bet my bf won't even want to look at me anymore." d. "do you think dark beige foundation would cover this scare on my cheek?"
d
Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. bp 95/48 per a-line b. serous exudate is leaking from burns c. cardiac monitor shows HR 108 d. u/o 20ml per hr past 2 hr
d
Esomeprazole (nexium) is prescribed for pt who incurred extensive burn injuries. 5 day ago. what nursing assessment would best eval. effectiveness? a. bowel sounds b. stool freq. c. abdominal d. stool for occult blood
d
In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? A. Serum sodium and potassium increase B. Serum sodium and potassium decrease. C. Edema and arterial blood gases improve D. Diuresis occurs and hematocrit decreases.
d
Nurse is reviewing MAR on a pt. with partial. thickness. burns. what med is best to admin before scheduled wound debridement? a. ketorolac (toradol) b. Lorazepam (Ativan) c. Gabapentin. (Neurontin) d. Hydromorphone (dilaudid)
d
The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? A. Severe pain, blisters, and blanching with pressure B. Pain, minimal edema, and blanching with pressure C. Redness, evidence of inhalation injury, and charred skin D. No pain, waxy white skin, and no blanching with pressure
d
Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.
d
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.
d
during the emergent phase, which assessment will be most useful in determining whether the pt is receiving adequate fluids? a. skin turgor b. daily weight c. assess mucous membrane d. hourly u/o
d
In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze
d,e,c,a,b
