Burns ATI Quiz bank questions

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? a. estimation of burn injury b. characteristics of the cough and sputum c. extent of peripheral edema d. amount of urine output

b. characteristics of the cough and sputum a client who has burns to the face is at risk for pulmonary injury, and the development of a brassy cough can indicate an impending loss of airway

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? a. hyponatremia b. leukopenia c. hyperchloremia d. elevated BUN

b. leukopenia transient leukopenia is an adverse effect of silver sulfadiazine

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? a. cadaver skin b. pig skin c. amniotic membranes d. beef collagen

b. pig skin heterografts are obtained from an animal, usually a pig

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? a. hemoglobin 10 g/dL b. sodium 132 mEq/L c. albumin 3.6 g/dL d. potassium 4.0 mEq/L

b. sodium 132 mEq/L this laboratory finding is below the expected reference range. the nurse should anticipate a low sodium level because sodium is trapped in interstitial space

A nurse is assessing a client who sustained superficial partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? a. edema in the burned extremities b. severe pain at the burn sites c. urine output of 30 mL/hr d. temperature of 102.4

d. temperature of 102.4 an elevated temperature is an indication of infection, and the nurse should report this finding to the provider. sepsis is a critical finding following a major burn injury. initially, burn wounds are relatively pathogen-free. on approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms

A nurse is caring for a client who has burn injuries on his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy Which of the following statements by the client indicates an understanding of the teaching? a. "I will be on a special shower table." b. "The water temperature will be very cool to ease my pain." c. "The nurse will use a firm-bristled brush to remove loose skin." d. "The nurse will use scissors to open small blisters."

a. "I will be on a special shower table." the special shower table facilitates examination and debridement of the wound during hydrotherapy. an advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature; there is also a lower risk of wound infection.

A nurse is caring for an adolescent who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? a. "May I go with my family to the visitors lounge? b. "I'll see my friends when I get home." c. "My dad is coming to visit. Can you fix my hair for me?" d. "I told my cousins I'm in protective isolation."

a. "May I go with my family to the visitor's longue?" this statement demonstrates a positive self-image since the client is asking to visit with her family in a public setting

A nurse is teaching a client who has extensive deep-partial and full-thickness burns and requires a topical antimicrobial medication. The goal of this medication therapy is to reduce which of the following outcomes? a. bacterial growth b. scarring c. skin graft size d. pain

a. bacterial growth topical antimicrobial medications help-prevent bacteria from entering the body when a client has an impairment of the protective covering of the skin; as with burns. it and the dressing create a protective barrier between bacteria and the exposed body tissues. this therapy helps prevent infections

A nurse is planning care for a client who has deep-partial-thickness burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? a. initiate range-of-motion exercises b. use clean technique to provide wound care c. place the client on a low-protein diet d. maintain the client on bed rest

a. initiate range-of-motion exercises the nurse should begin performing active and passive range-of-motion exercises with the client to maintain mobility and prevent contractures

a nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is the top priority? a. monitor intake and output b. administer antibiotics c. monitor respiratory status d. encourage fluid and food intake

c. monitor respiratory status smoke inhalation most likely includes a thermal injury to the tracheobronchial tree. edema from the inflammatory response to heat can obstruct the airway. endotracheal intubation may become necessary to maintain a patent airway