Burns... Randoms

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first? 1.A victim experiencing dyspnea 2.A victim experiencing confusion 3.A victim experiencing tachycardia 4.A victim experiencing intense pain

1.A victim experiencing dyspnea The client experiencing dyspnea is the priority. Needs related to maintaining a patent airway are always the priority. The victims experiencing confusion, tachycardia, and intense pain would be assessed following stabilization of the client with an airway problem.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1.A pregnant woman who exclaims, "My baby is not moving." 2.A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3.A young child standing next to an adult family member who is screaming, "I want my mommy!" 4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

2.A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!"Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply. 1.A client with dyspnea 2.A client experiencing sinus rhythm 3.A client receiving oral anticoagulants 4.A client with chronic atrial fibrillation 5.A client experiencing third-degree heart block6.A client who has not voided since before surgery

2.A client experiencing sinus rhythm 3.A client receiving oral anticoagulants 4.A client with chronic atrial fibrillation Clients should be medically stable if discharged and should be able to manage their condition at home independently, with family assistance, or with community services. The client in option 2 is stable because sinus rhythm is a normal finding. Oral anticoagulants can be taken at home as long as the client understands how to take the medication and is provided with education about the medication. The client in option 4 can be discharged because the client's condition is chronic, not acute. The client experiencing dyspnea is not considered stable. The client experiencing third-degree heart block is considered unstable and will most likely need a pacemaker insertion. Clients should not be discharged after surgery until they have voided.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1.A client with chest pain 2.A client with a Holter monitor 3.A client receiving oral antibiotics 4.A client experiencing sinus rhythm 5.A client newly diagnosed with atrial fibrillation 6.A client experiencing third-degree heart block who requires a pacemaker

2.A client with a Holter monitor 3.A client receiving oral antibiotics 4.A client experiencing sinus rhythm Clients should be medically stable if discharged and should be able to manage their condition at home. A client experiencing chest pain could be having a myocardial infarction and needs frequent monitoring. A client newly diagnosed with atrial fibrillation requires medication and monitoring to stabilize the condition. A client in third-degree heart block is considered unstable, especially if the client needs a pacemaker.

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1.The client with heart failure (HF) who has bilateral rhonchi 2.The client who 24 hours earlier gave birth to her second child by caesarean delivery 3.The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis 4.The client with peritonitis caused by a ruptured appendix who is febrile with a temperature of 102°F (38.9°C) 5.The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker 6.The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation

2.The client who 24 hours earlier gave birth to her second child by caesarean delivery 3.The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis 5.The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker 6.The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation The client who remains febrile with peritonitis and the client who has continuing rhonchi with heart failure need to be monitored on an ongoing basis. The remaining clients could be cared for at home with the help of a home health care nurse.

Which client should the emergency department triage nurse classify as emergent? 1.A client with a displaced fracture who is crying 2.A client with a simple laceration and soft tissue injury 3.A client with crushing substernal pain who is short of breath 4.A client with a temperature of 101°F (38.3°C) with a productive cough

3.A client with crushing substernal pain who is short of breath A triage method commonly used in the emergency department consists of 3 categories: emergent, urgent, and nonurgent. The emergent category implies that a condition exists that poses an immediate threat to life or limb. An example of a client who fits into this category is the client experiencing crushing substernal pain who is short of breath. The urgent category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. The client with a displaced fracture who is crying and the client with a temperature of 101°F (38.3°C) and a productive cough would fit into this category. The nonurgent category indicates that the client can generally tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple laceration and soft tissue injury would fit into this category.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1.A victim experiencing excruciating pain 2.A victim experiencing moderate anxiety 3.A victim experiencing airway obstruction 4.A victim experiencing altered level of consciousness

3.A victim experiencing airway obstruction Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1.A middle-aged man with 1 foot trapped under the wreckage 2.A crying teenager who is holding pressure on an arm laceration 3.A young woman who appears dazed and confused and is shivering 4.A screaming middle-aged woman looking frantically for her husband

3.A young woman who appears dazed and confused and is shivering The young woman is demonstrating classic signs of shock, possibly from a closed head injury. Initial management of a client displaying signs of shock includes management of airway, breathing, and circulation. Initial treatment includes keeping the client warm. Oxygenation and intravenous fluids will be needed immediately to stabilize and maintain tissue perfusion. A first responder would be unlikely to be able to release a foot trapped under wreckage without help. The teenager is already applying pressure to the arm and is more likely to be able to maintain self-care until help arrives. Assisting a client with search and rescue would only be feasible once help arrives. Therefore, the nurse should attend to the client with the priority needs and the greatest potential of survival.

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? 1.Fractured tibia 2.Penetrating abdominal injury 3.Bright red bleeding from a neck wound 4.Open massive head injury in deep coma

3.Bright red bleeding from a neck wound The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last.

Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last. 1. A 50-year-old female with moderate abdominal pain and occasional vomiting. 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity. 3. An ambulatory dazed 25-year-old male with a bandaged head wound. 4. An irritable infant with a fever, petechiae, and nuchal rigidity

4, 3, 1, 2 An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, a medical evaluation can be delayed 24 - 48 hours if necessary.

You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as:* A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness)

B. These are the classic characteristics of a 2nd degree (partial-thickness) burn.

A nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of his body 24 hr ago. Which of the following are findings should the nurse expect? (Select all that apply) A. Dyspnea B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit

A, C, & D A: Dyspnea can occur during the initial phase following a burn due to airway injury and fluid shifts. C: Hyperkalemia occurs during the initial phase following a burn as a result of leakage of fluid from the intracellular space. D. Hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space.

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A. Limit visitors in the room B. Encourage fresh vegetables in the diet C. Increase protein intake D. Instruct the client to consume 2,000 calories/day E. Restrict fresh flowers in the room

A, C, & E A: The nurse should limit the number of visitors and limit the amount of time they can visit to decrease the risk of infection.C: The client should increase protein consumption, which promotes wound healing and prevents tissue breakdown.E: Flowers should not be in the client's room due to the bacteria they carry, which increases the risk for infection.

A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a:* A. 1st degree (superficial) burn B. 2nd degree (partial-thickness) burn C. 3rd degree (full-thickness) burn D. 4th degree (deep full-thickness) burn

A. These are the classic characteristics of a 1st degree, superficial burn.

Which statement below is INCORRECT about the yellow triage tag color in regards to a disaster situation? A. A survivor with this tag color is seen after patients with the green tag color. B. A survivor with this tag color can have treatment delayed for an hour or less. C. A survivor with this tag color has serious injuries that could eventually lead to the compromise of breathing, circulation, or mental status, especially if treatment is delayed more than an hour or so. D. A survivor with this tag color has second priority for treatment of injuries.

A. This statement is INCORRECT. It should say: A survivor with this tag color is seen after patients with the RED (not green) tag color.

A patient with a major burn is receiving silver sulfadiazine (Silvadene) treatment. What nursing action should be implemented when using this medication? A. Monitor WBC count daily B. Observe for signs of dehydration C. Monitor serum electrolyte levels daily D. Premedicate for pain prior to application

A. Monitor WBC count daily

A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document the burn? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full thickness

A. superficial thickness A sunburn is a superficial thickness burn. Superficial burns damage the top layer of the skin.

The wounded victim is able to walk and obey commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

A: Green.

The nurse is calculating the percentage of total body surface area that has been burned for a patient with deep partial-thickness burns to the anterior trunk, perineum, and anterior and posterior left arm. Using the "rule of nines" what is the percent of TBSA that was burned? A. 18% B. 28% C. 36% D. 40%

B. 28%

A patient weighing 70kg is being treated for full-thickness burns over 50% of the body. Using the Consensus formula, calculate the amount of fluid replacement that the nurse should deliver in the first 8 hours. A. 3500 mL B. 7000 mL C. 10,500 mL D. 14,000 mL

B. 7000 mL

The nurse is caring for a patient with deep partial-thickness burns to the entire left arm and left side of the back. After a routine assessment, what finding should be immediately reported to the physician? A. Pain in the left arm B. decreased left radial pulse C. fluid-filled vesicles on the left arm D. blanching when pressure applied to the left hand

B. decreased left radial pulse

The wounded victim is unable to walk, has respiratory rate of 12, capillary refill is 8 seconds, and is unresponsive. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

B: Red.

The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

B: Red.

The wounded victim is unable to walk, respiratory rate is absent but when airway is repositioned breathing is noted. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

B: Red.

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor? A. Red B. Yellow C. Green D. Black

C Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the "walking wounded"

The nurse is planning an educational program on burn prevention for residents of a senior citizen center. Which topics should the nurse include in this presentation? (Select all that apply) A. Use a solar-powered nightlight B. Check smoke detectors annually C. Set the water heater no higher than 120 degrees D. Wear close-fitting clothing when cooking E. Install antiscald devices in bathroom plumbing F. Have a neighbor routinely check for the odor of gas

C, D, E, & F

A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full-thickness burns over 60% of his body 24 hr ago. The nurse should plan to use which of the following routes to administer the medication? A. Subcutaneous B. Oral C. IV D. Transdermal

C. IV The nurse should use the IV route to admin pain medication for rapid absorption and fast pain relief during the resuscitation phase.

A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Of this total, 20% are full-thickness burns on the arms, face, neck, and shoulders. The client's voice has become hoarse. He has a brassy cough and is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning

C. Inhalation injury Wheezing and hoarseness indicate inhalation injury with impending loss of the airway. These require immediate reporting to the provider.

The nurse is reviewing laboratory values for a patient receiving treatment during the emergent phase of burn management. Which laboratory result should the nurse expect for the patient at this time? A. increased hematocrit B. increased serum albumin C. decreased serum potassium D. decreased blood urea nitrogen

C. decreased serum potassium

You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first? A. Green B. Yellow C. Red D. Black

C: Red. The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The patient is still alive but there is a severe alteration in their breathing, circulation, or mental status that requires immediate medical attention.

The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second, and is able to obey your commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

C: Yellow.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? a. Full liquids only b. Whatever the patient requests c. High-protein and low-sodium foods d. High-calorie and high-protein foods

d. High-calorie and high-protein foods c

A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can't move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to? A. Black. B. Green. C. Red. D. Yellow

D. Yellow.

The nurse is evaluating the effectiveness of fluid resuscitation provided to a patient with a major burn. Which evaluation criterion indicates that fluid resuscitation has been effective during the first 24 hours of care? A. blood pressure 96/70 mmHg B. heart rate of 130/bpm C. central venous pressure of 18 D. urine output 30 to 50 mL/h

D. urine output 30 to 50 mL/h

The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

D: Black.

While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned? A. Green B. Red C. Yellow D. Black

D: Black. The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status.

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 Brisk bleeding from the site Decreasing edema formation Formation of granulation tissue

Return of distal pulses Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? a. Administer 100% humidified oxygen. b. Teach the patient deep breathing exercises. c. Encourage the patient to express his feelings. d. Assist the patient to a high Fowler's position.

a. Administer 100% humidified oxygen.

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. blisters d. intact nerve endings e. red, shiny, wet appearance

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. Reddening of the skin

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? a. Skin is hard with a dry, waxy white appearance. b. Skin is shiny and red with clear, fluid-filled blisters. c. Skin is red and blanches when slight pressure is applied. d. Skin is leathery with visible muscles, tendons, and bones.

b. Skin is shiny and red with clear, fluid-filled blisters.

The skin of a patient with severe burns to the face and chest is dry and leathery, with no pain sensations present. How should the nurse classify this burn? A. Superficial B. full thickness C. deep partial thickness D. superficial partial thickness

b. full thickness

A 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. observe the wound for signs of infection during dressing changes

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as a. full-thickness skin destruction. b. deep full-thickness skin destruction. c. deep partial-thickness skin destruction. d. superficial partial-thickness skin destruction.

c. deep partial-thickness skin destruction.

The nurse is triaging recent patients brought to the burn center. Which patient is most at risk for developing burn shock? A. 30-year-old with 10% TBSA from a gasoline explosion B. 21-year-old with 90% superficial burn from the tanning bed C. 39-year-old with radiation burns following treatment for cancer D. 48-year-old with >50% TBSA from a high voltage electrical accident

d. 48-year-old with >50% TBSA from a high voltage electrical accident

A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on 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. No pain, waxy white skin, and no blanching with pressure

A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultated 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. encourage the patient to cough and auscultate the lungs again b. obtain vital signs, oxygen saturation, and a STAT ABG c. document the findings and continue to monitor the patient's breathing d. anticipate the need for endotracheal intubation and notify the physician

d. anticipate the need for endotracheal intubation and notify the physician