NCLEX Emergency/Burns/Triage

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

D ~ Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the walking wounded and classified as nonurgent.

The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply. 1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses 5. 4-week supply of water 6. 4-week supply of nonperishable food

1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses Options 1, 2, 3, and 4 should be identified as items to have on hand as part of disaster preparedness. A 3-day supply of water is recommended (1 gallon per client per day). Similarly, a 3-day supply of nonperishable food is recommended. A 4-week supply of water and food is unnecessary and not recommended.

The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client's plan of care? a. Administer a sedative medication. b. Ask a family member to stay with the client. c. Use restraints to prevent the client from falling. d. Place the client in a wheelchair at the nurses' station.

ANS: B Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls.

When evaluating the laboratory values of the burn-injured patient, which of the following can be anticipated? 1. decreased hemoglobin and elevated hematocrit levels 2. elevated hemoglobin and elevated hematocrit levels 3. elevated hemoglobin and decreased hematocrit levels 4. decreased hemoglobin and decreased hematocrit levels 5. hemoglobin and hematocrit levels within normal ranges

Correct Answer: 1 Rationale: Hemoglobin levels are reduced in response to the hemolysis of red blood cells. Hematocrit levels are elevated secondary to hemoconcentration, and fluid shifts from the intravascular compartment.

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? 1. inability of the damaged capillaries to maintain fluids in the cell walls 2. reduced vascular permeability at the site of the burned area 3. decreased osmotic pressure in the burned tissue 4. increased fluids in the extracellular compartment 5. the IV fluid being administered too quickly

Correct Answer: 1 Rationale: Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments. Manifestations of fluid volume overload would be systemic, not localized to the burn areas.

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? 1. Check breathing and circulation. 2. Look for entrance and exit wounds. 3. Cover the patient to prevent heat loss. 4. Move the patient indoors to a dry place. 5. Get the patient up off the ground.

Correct Answer: 1 Rationale: Cardiopulmonary arrest is the most common cause of death from lightening. Respiratory and cardiac status should be assessed immediately to determine if CPR is necessary. All other actions are secondary.

The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise? 1. Primary level of prevention 2. Secondary level of prevention 3. Tertiary level of prevention 4. Quaternary level of prevention

3. Tertiary level of prevention Tertiary prevention involves reduction of the amount and degree of disability, injury, and damage after a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of a crisis. There is no known quaternary prevention level.

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.

Place an "X" over the section of the diagram that represents the depth of a superficial partial-thickness burn. [insert Use figure 16-17 in LeMone 5E. Remove the caption and the labels on the right side (Clark's levels). Retain the left side labels (Skin layers). The Roman numeral labels in the drawing may remain if necessary.]

Rationale : A superficial partial-thickness burn damages the entire epidermis and through the papillary dermis.

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 in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse? 1. Call the nursing supervisor to activate the agency disaster plan. 2. Supply the triage rooms with bottles of sterile water and normal saline. 3. Call the intensive care unit to request that nurses be sent to the emergency department. 4. Call the laundry department, and ask the department to send as many warm blankets as possible to the emergency department.

1. Call the nursing supervisor to activate the agency disaster plan. In an external disaster, many people may be brought to the emergency department for treatment. The initial nursing action must be to activate the disaster plan. Although options 2, 3, and 4 may be additional measures that the nurse would take, the initial action would be to activate the disaster plan.

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 block 6. 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 is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply. 1. Provide monetary relief. 2. Provide crisis counseling. 3. Identify and train personnel. 4. Issue presidential declarations. 5. Deploy National Guard troops. 6. Handle inquiries from families.

2. Provide crisis counseling. 3. Identify and train personnel. 6. Handle inquiries from families. In general, the ARC provides support to individuals involved in a disaster, whereas FEMA deals with regional responses to disasters, such as issuing presidential declarations, providing monetary relief, and deploying National Guard troops. The ARC has been given authority by the federal government to identify and train personnel for a disaster and provide disaster relief, including crisis counseling, operating shelters, and handling inquiries from families.

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 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.

The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. You are free to express your feelings; whatever is said here stays here. b. Lets evaluate what went wrong and develop policies for future incidents. c. This session is only for nursing and medical staff, not for ancillary personnel. d. Lets pass around the written policy compliance form for everyone.

A ~ Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurses interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

A ~ The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

A ~ The nurse should first provide emotional support by encouraging relaxation, listening to the family's needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the family's needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the family's needs.

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

A ~ To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each others stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.

A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. b. The government has a program for quick licensure activation wherever you are deployed. c. During a time of crisis, licensure issues would not be the governments priority concern. d. If you are deployed, you will be issued a temporary license in the state in which you are working.

A ~ When deployed, DMAT health care providers are acting as agents of the federal government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (SATA) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

A, C, D, F ~ Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (SATA) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

A, D ~ Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag.

The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.) a. A 50-year-old with chest trauma and difficulty breathing b. A mother frantically looking for her 6-year-old son c. An 8-year-old with a broken leg in his father's arms d. A 60-year-old with facial lacerations and confusion e. A pulseless male with a penetrating head wound

ANS: a, d, b, c, e Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client with chest trauma and difficulty breathing is the priority because no clients have an airway problem, and this is the only client with a breathing problem. The client with confusion should be seen next. Confusion can be caused by lack of oxygen to the brain due to a circulation problem. The pulseless client with a penetrating head wound is seen last because there are multiple clients to be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can wait. The mother looking for her son should be seen third. Finding the child is urgent to identify potential injuries.

In what sequence would a client move through the process of admission to disposition in emergency care? (Place in order of priority.) a. Client is transported to the medical-surgical floor. b. Emergency department (ED) nurse gives a report on the client. c. Paramedics arrive and start IV access. d. Nurse and other health care provider(s) perform assessment. e. Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring. f. Laboratory technician obtains blood specimens.

ANS: e, c, d, f, b, a When clients are in an emergency situation, EMTs arrive on the scene first. EMTs apply oxygen and obtain vital signs to determine a baseline for further care. EMTs can provide basic life support measures and can assess ABCs. Second on the scene are paramedics. Starting IV access and performing advanced life support is within the paramedic's scope of practice. The client is then transported to an ED, where nurses and other health care providers perform an initial assessment. Laboratory technicians are notified and appropriate blood specimens are obtained for diagnostic testing. When the client is stable, the ED nurse gives report to the medical-surgical unit nurse, and the client is finally transferred to an inpatient room.

The nurse is triaging clients in the emergency department (ED). Which is true about the presentation of client symptoms? a. Older adults frequently have symptoms that are vague or less specific. b. Young adults present with nonspecific symptoms for serious illnesses. c. Diagnosing children's symptoms often keeps them in the ED longer. d. Symptoms of confusion always represent neurologic disorders.

ANS: A Older adults present with symptoms that often are different or less specific than those of younger adults. For example, increasing weakness, fatigue, and confusion may be the only admission concerns. These vague symptoms can be caused by serious illness, such as an acute myocardial infarction (MI), urinary tract infection, or pneumonia. Diagnosing older adults often keeps them in the ED for extended periods of time.

A client has been injured in a stabbing incident. Assessment reveals the following: Blood pressure: 80/60 mm Hg Heart rate: 140 beats/min Respiratory rate: 35 breaths/min Bleeding from stabbing wound site Client is lethargic Based on these assessment data, to which trauma center should the nurse ensure transport of the client? a. Level I b. Level II c. Level III d. Level IV

ANS: A The Level I trauma center is able to provide a full continuum of care for all client areas. Level II can provide care to most injured clients, but given the extent of his injuries, a Level I center would be better if it is available. Both Levels III and IV can stabilize major injuries, but transport to a higher-level center is preferred, when possible.

A new nurse is orienting to the emergency department (ED). Which statement made by the nurse would indicate the need for further education by the preceptor? a. "The emergency medicine physician coordinates care with all levels of the emergency health care team." b. "Emergency departments have specialized teams that deal with high-risk populations of patients." c. "Many older adults seek emergency services when they are ill because they do not want to bother their primary health care provider." d. "Emergency departments are responsible for public health surveillance and emergency disaster preparedness."

ANS: A The emergency nurse is one member of the large interdisciplinary team that provides care for clients in the ED. A collaborative team approach to emergency care is considered a standard of practice. In this setting, the nurse coordinates care with all levels of health care team providers, from prehospital emergency medical services (EMS) personnel to physicians, hospital technicians, and professional and ancillary staff.

The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do first? a. Assess that the client is breathing adequately b. Insert a large-bore intravenous line c. Place the client on a cardiac monitor d. Assess for best neurologic response

ANS: A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he may not be breathing, or he may be breathing inadequately with the device in place.

The nurse is discharging an older adult client home from the emergency department (ED) after an acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select all that apply.) a. Reconcile the client's prescription and over-the-counter medications b. Screen the client for functional and cognitive abilities, as well as risk for falls c. Consult physical therapy to organize for home health services d. Arrange for the client's car keys to be taken to prevent an accident e. Review discharge instructions with the client and a family member

ANS: A, B, E Before discharge, the nurse should ensure that the client's prescription and over-the-counter medications are evaluated to determine whether the drug regimen should be continued. Discharge education should be provided to the client and a significant other or family member. To prevent future ED visits, screen older adults per agency policy for functional assessment, cognitive assessment, and risk for falls. Case management should be consulted to organize home health services. The nurse should emphasize safety when driving but cannot organize to take the client's keys away.

The emergency department (ED) nurse is preparing to transfer a client to the critical care unit. What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Allergies b. Vital signs c. Immunizations d. Marital status e. Isolation precautions

ANS: A, B, E Hand-off communication should be comprehensive so that the nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, transmission-based precautions needed, interventions provided, and response to those interventions.

Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.) a. Removing wet clothing b. Splinting open fractures c. Initiating IV fluids d. Endotracheal intubation e. Foley catheterization f. Needle decompression g. Laceration repair

ANS: A, C, D, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: A, airway and cervical spine control; B, breathing; C, circulation; D, disability; and E, exposure. After completion of primary diagnostic studies and laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete head-to-toe assessment, can be carried out.

The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first? a. 22-year-old with a painful and swollen right wrist b. 45-year-old reporting chest pain and diaphoresis c. 60-year-old reporting difficulty swallowing and nausea d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F

ANS: B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first? a. Place the client on a non-rebreather mask. b. Begin bag-valve-mask ventilation. c. Initiate cardiopulmonary resuscitation. d. Prepare for chest tube insertion.

ANS: B Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax.

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. What should the nurse do next? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.

ANS: B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Triage the client to determine the urgency of care. b. Clearly communicate client data to the unit nurse. c. Evaluate the need for ongoing medical treatment. d. Perform a thorough assessment of the client.

ANS: B The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client's ED experience.

A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent? a. Chest pain and diaphoresis b. Decreased breath sounds due to chest trauma c. Left arm fracture with palpable radial pulses d. Sore throat and a temperature of 104° F

ANS: C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent.

The nurse is triaging clients in the emergency department. Which client should be considered urgent? a. 20-year-old female with a chest stab wound and tachycardia b. 45 year-old homeless man with a skin rash and sore throat c. 75-year-old female with a cough and of temperature of 102° F d. 50-year-old male with new-onset confusion and slurred speech

ANS: C A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

While assessing a client in the emergency department, the nurse identifies that the client has been raped. Which health care team member should the nurse collaborate with when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

ANS: C All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

The nurse is caring for a homeless client and consults the emergency department (ED) case manager. What can the ED case manager do for this client? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

ANS: C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage? a. Treat clients on a first-come, first-serve basis. b. Identify and treat clients with low acuity first. c. Prioritize clients based on illness severity. d. Determine health needs from a complete assessment.

ANS: C ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the "head of the line."

The nurse is providing care for a client admitted for suicidal precautions. What priority intervention should the nurse implement first? a. Administer prescribed anti-anxiety drugs. b. Decrease the noise level and the harsh lighting. c. Remove oxygen tubing from the room. d. Set firm behavioral limits.

ANS: C The first priority in caring for a mentally ill client is providing a safe environment. This would include removing any item that the client could use to harm himself or herself (or others). All the other interventions can be used in providing a therapeutic environment. However, they are not as imperative as the safety of the client and staff.

A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face, as well as an open right femur fracture that is bleeding profusely. What will the nurse do first? a. Splint the right lower extremity. b. Apply direct pressure to the leg. c. Assess for a patent airway. d. Start two large-bore IVs.

ANS: C The highest-priority intervention in the primary survey is to establish a patent airway. Without an adequate airway to supply oxygen to the cells, a cerebral injury could progress to anoxic brain death. After an airway is established, resuscitation may continue to B for breathing and C for circulation assessment.

The nurse manager is assessing current demographics of the facility's emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat? a. Older adults b. Immunocompromised people c. Pediatric clients d. Underinsured people

ANS: D The ED serves as an important safety net for clients who are ill or injured but lack access to basic health care. Especially vulnerable populations include the underinsured and the uninsured, who may have nowhere else to go for health care.

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 1. in the outpatient ambulatory clinic. 2. in the emergency department. 3. in a burn center. 4. in the doctor's office and then at home.

Correct Answer: 3 Rationale: Adult patients who should be treated at burn centers include those with burns that involve the hands, feet, face, eyes, ears, or perineum. Patients having small or noninvasive burns may be managed at an outpatient clinic are mild in nature. The emergency department is a location for evaluation of a burn. The physician's office like the ambulatory clinic can manage mild burns.

On admission to the emergency department, a client states that he feels like killing himself. When planning this client's care, it is most important for the nurse to coordinate with which member of the health care team? a. Case manager b. Forensic nurse examiner c. Physician d. Psychiatric crisis nurse

ANS: D The psychiatric crisis nurse interacts with clients and families in crisis. This health care team member can offer valuable expertise to the emergency health care team, which also includes the case manager and the physician.

A client in the emergency department has died from a suspected homicide. What is the nurse's priority intervention? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.

ANS: D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time? a. Are you sure no more victims are coming into the ED? b. Do all areas of the hospital have the supplies and personnel they need? c. Have all ED staff had the chance to eat and rest recently? d. Does the Chief Medical Officer agree this disaster is under control?

B ~ Before standing down, the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more walking wounded victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can stand down.

A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (SATA) a. Paramedic Decides the number, acuity, and resource needs of clients b. Hospital incident commander Assumes overall leadership for implementing the emergency plan c. Public information officer Provides advanced life support during transportation to the hospital d. Triage officer Rapidly evaluates each client to determine priorities for treatment e. Medical command physician Serves as a liaison between the health care facility and the media

B, D ~ The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (SATA) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

B, E ~ The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis.

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. b. Not everyone will survive a disaster, so it is best to identify those people early and move on. c. In a disaster, extensive resources are not used for one person at the expense of many others. d. With black tags, volunteers can identify those who are dying and can give them comfort care.

C ~ In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not sacrificed. Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

C ~ The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff members individually does not provide the same level of support as a group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as a debriefing.

A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, "I cant believe that my wife is gone and I am left to raise my children all by myself." How should the nurse respond? a. Please accept my sympathies for your loss. b. I can call the hospital chaplain if you wish. c. You sound anxious about being a single parent. d. At least your children still have you in their lives.

C ~ Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the clients distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the clients feelings and situation.

A patient with third-degree burns is prescribed gastrointestinal medication. The primary action of this drug is which of the following? 1. to prevent the onset of a Curling's ulcer 2. to treat a preexisting duodenal ulcer 3. to ensure adequate peristalsis 4. for the antiemetic properties

Correct Answer: 1 Rationale: Dysfunction of the gastrointestinal system is directly related to the size of the burn wound. This can lead to a cessation of intestinal motility, which causes gastric distention, nausea, vomiting, and hematemesis. Stress ulcers or Curling's ulcers are acute ulcerations of the stomach or duodenum that form following the burn injury. There is no evidence to support the presence of a preexisting duodenal ulcer. Although peristalsis is desired, it is not the primary area of gastrointestinal concern. There is no data presented to indicate the presence of nausea or vomiting.

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? 1. a moderate burn 2. a minor burn 3. a major burn 4. a severe burn 5. an intermediate burn

Correct Answer: 1 Rationale 1: A moderate burn is a partial-thickness injury that is between 15%-25% of total body surface area in adults.

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? 1. major 2. moderate 3. minor 4. superficial 5. intermediate

Correct Answer: 1 Rationale 1: Partial-thickness injuries of greater than 25% of total body surface area in adults and full-thickness injuries 10% or greater of TBSA are considered major burns.

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 1. is developing a hypersensitivity to the medication. 2. is reacting positively to the medication. 3. needs an increase in dosage of the medication. 4. is not responding to the medication.

Correct Answer: 1 Rationale: Approximately 3%-5% of patients develop a hypersensitivity to mafenide, which can manifest as facial edema. The manifestation of facial and neck edema is considered an adverse reaction. There is inadequate information presented to assess response to the medication.

A patient has experienced a burn injury. Which of the following interventions by the nurse is of the highest priority at this time? 1. determination of the type of burn injury 2. determination of the types of home remedies attempted prior to the patient's coming to the hospital 3. assessment of past medical history 4. determination of body weight 5. determination of nutritional status

Correct Answer: 1 Rationale: Determination of the type of burn is the first step. The type of injury will dictate the interventions performed. Determining the use of home remedies, past medical history, body weight, and nutritional status must be completed, but are not of the highest priority.

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) 1. glomerular filtration rate (GFR) reduced 2. specific gravity elevated 3. creatinine clearance reduced 4. BUN reduced 5. uric acid decreased

Correct Answer: 1,2 Rationale: During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in reduction in GFR and an increase in specific gravity. During this period, BUN levels, creatinine, and uric acid are increased

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 ofwound debridement is this nurse using? 1. enzymatic 2. mechanical 3. surgical 4. topical

Correct Answer: 1 Rationale: Enzymatic debridement involves the use of a topical agent to dissolve and remove necrotic tissue. An enzyme such as Elase is applied in a thin layer directly to the wound and covered with one layer of fine mesh gauze. A topical antimicrobial agent is then applied and covered with a bulky wet dressing. Mechanical debridement may be performed by applying and removing gauze dressings, hydrotherapy, irrigation, or using scissors and tweezers. Surgical debridement is the process of excising the wound to the fascia or removing thin slices of the burn to the level of viable tissue. Topical treatments are key in the care of a burn but do not involve debridement.

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? 1. glycosuria 2. creatine phosphokinase (CPK) 3. BUN levels 4. hemoglobin 5. serum sodium levels

Correct Answer: 1 Rationale: Glucose in the urine is seen after a major burn injury. It signals the need to reevaluate the patient's nutritional plan. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury dependent upon the fluid status. Serum sodium levels are not indicative of nutritional status.

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 1. 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.

Correct Answer: 1 Rationale: Intake and output measurements indicate the adequacy of fluid resuscitation, and should range from 30 to 50 mL per hour in an adult.

A patient recovering from a major burn injury is complaining of pain. Which of the following medications will be most therapeutic to the patient? 1. morphine 4 mg IV every 5 minutes 2. morphine 10 mg IM ever 3-4 hours 3. meperidine 75 mg IM every 3-4 hours 4. meperidine 50 mg PO every 3-4 hours 5. fentanyl citrate (Duragesic) 75 mcg patch every 3 days

Correct Answer: 1 Rationale: Morphine is preferred over meperidine for the burn-injured patient. Typical dose of morphine is 3-5 mg every 5-10 minutes for an adult. The intravenous route is preferred over oral and intramuscular routes. A transdermal patch would not be used because of decreased absorption of the medication through the skin of the burn-injured patient.

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? 1. increasing fluid intake 2. applying mild lotions 3. taking mild analgesics 4. maintaining warmth 5. using sunscreen

Correct Answer: 1 Rationale: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important. Other manifestations could include nausea and vomiting. All the measures help alleviate the manifestations of this minor burn which include pain, skin redness, chills, and headache. Use of sunscreen is a preventative, not a treatment measure.

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? 1. the resolution of burn shock 2. the onset of burn shock 3. the onset of renal failure 4. the onset of liver failure

Correct Answer: 1 Rationale: Potassium levels are initially elevated during burn shock but will decrease after burn shock resolves as fluid shifts back to intracellular and intravascular compartments. Reduced potassium levels are not indicators of the onset of renal or liver failure.

Following surgical debridement, a patient with third-degree burns does not bleed. The nurse realizes that this patient 1. will need to have the procedure repeated. 2. will no longer need this procedure. 3. will need to be premedicated prior to the next procedure. 4. should have an escharotomy instead.

Correct Answer: 1 Rationale: Surgical debridement is the process of excising the burn wound by removing thin slices of the wound to the level of viable tissue. If bleeding does not occur after the procedure, it will be repeated. It is an assumption that patients having debridement will all require premedication. An escharotomy involves removal of the hardened crust covering the burned area.

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? 1. These values are normal for the patient's post-burn injury condition. 2. The patient is demonstrating manifestations consistent with the onset of an infection. 3. The patient is demonstrating manifestations consistent with an electrolyte imbalance. 4. The patient is demonstrating manifestations consistent with renal failure. 5. The patient is demonstrating manifestations of fluid volume overload.

Correct Answer: 1 Rationale: The burn-injured patient is not considered tachycardic until the heart rate reaches 120 beats per minute. In the absence of other symptoms, the temperature does not signal the presence of an infection. It could be a response to a hypermetabolic response.

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? 1. Medicate for pain. 2. Empty the patient's in-dwelling catheter collection bag. 3. Change the patient's bed linens. 4. Change the dressing on the burn.

Correct Answer: 1 Rationale: The nurse should anticipate this patient's needs for analgesia and administer pain medication to promote the patient's comfort during the exercise session. Arm exercise is not related to the amount of urine in the catheter bag. Linen changes do not impact range of motion activities. The burn's dressing is changed according to the physician's orders or as needed.

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? 1. "You will begin to perform exercises to promote flexibility and reduce contractures after five days." 2. "You will need to report any itching, as it might signal infection." 3. "Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve success of the procedure." 4. "The procedure will be performed in your room." 5. "You will need to be in protective isolation for several weeks after the graft is performed."

Correct Answer: 1 Rationale: The patient will begin to perform range-of-motion exercises after five days. Itching is not a symptom of infection but an anticipated occurrence that signals cellular growth. The ideal time to perform the procedure is early in the treatment of the burn injury. The procedure is performed in a surgical suite. Patients with skin grafts do not require protective isolation.

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? 1. The amount of urine will be reduced in the first 24-48 hours, and will then increase. 2. The amount of urine output will be greatest in the first 24 hours after the burn injury. 3. The amount of urine will be reduced during the first eight hours of the burn injury and will then increase as the diuresis begins. 4. The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. 5. The amount of urine is expected to be decreased for three to five days.

Correct Answer: 1 Rationale: The patient will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the patient will enter a period of diuresis. The diuresis begins between 24 and 36 hours after the burn injury.

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? 1. "The scabs are really old burned tissue and need to be removed to promote healing." 2. "I'll ask the doctor to come and talk with you about the treatment plan." 3. "The patient asked for the scabs to be removed." 4. "The scabs are removed to check for blood flow to the burned area."

Correct Answer: 1 Rationale: The patient's family is describing eschar, which is the hard crust of burned necrotic tissue. Eschar needs to be removed to promote wound healing. Option 2 does not answer the family's question. Option 3 incorrectly restates the family's concern. Scabs are not removed to check for blood flow.

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? 1. The wound is a deep partial-thickness burn, and will take more than three weeks to heal. 2. The wound is a partial-thickness burn, and could take up to two weeks to heal. 3. The wound is a superficial burn, and will take up to three weeks to heal. 4. The wound is a full-thickness burn and will take one to two weeks to heal. 5. Wound healing is individualized.

Correct Answer: 1 Rationale: The wound described is a deep partial-thickness burn. Deep partial-thickness wounds will take more than three weeks to heal. A superficial burn is bright red and moist, and might appear glistening with blister formation. The healing time for this type of wound is within 21 days. A full thickness burn involves all layers of the skin and may extend into the underlying tissue. These burns take many weeks to heal. Stating that wound healing is individualized does not answer the patient's question about the severity of the burn.

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? 1. Powerlessness 2. Potential for Infection 3. Fluid Volume Deficit 4. Risk for Ineffective Airway Clearance

Correct Answer: 1 Rationale: This patient can begin to experience powerlessness in that she has no control over the outcome of healing on scar formation to her face. The nurse should allow the patient to express feelings in efforts to help the patient cope with the news of potential scarring. The patient with a third-degree burn is at risk for infection, however, this question is focused on the impact of her facial scarring. There is inadequate information to determine the patient's risk for fluid volume deficit or ineffective airway clearance. Further, this is not the focus of the question.

A patient is coming into the emergency department with third-degree burns over 25% of his body. The nurse should prepare which of the following solutions for intravenous infusion for this patient? 1. warmed lactated Ringer's 2. 5% dextrose in water 3. 5% dextrose in 0.45 normal saline 4. 5% dextrose in normal saline

Correct Answer: 1 Rationale: Warmed Ringer's lactate solution is the intravenous fluid most widely used during the first 24 hours after a burn injury because it most closely approximates the body's extracellular fluid composition.

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? 1. warmed lactated Ringer's solution 2. dextrose 5% with saline solution 3. dextrose 5% with water 4. normal saline solution 5. 0.45% saline solution

Correct Answer: 1 Rationale: Warmed lactated Ringer's solution is the IV solution of choice because it most closely approximates the body's extracellular fluid composition. It is warmed to prevent hypothermia.

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. 1. a superficial partial-thickness burn 2. a thermal burn 3. a superficial burn 4. a deep partial-thickness burn 5. a full-thickness burn

Correct Answer: 1,2 Rationale: Superficial partial-thickness burn if often bright red, has a moist, glistening appearance and blister formation. Thermal burns result from exposure to dry or moist heat. A superficial burn is reddened with possible slight edema over the area. A deep partial-thickness burn often appears waxy and pale and may be moist or dry. A full-thickness burn may appear pale, waxy, yellow, brown, mottled, charred, or non-blanching red with a dry, leathery, firm wound surface.

A patient with a burn injury is prescribed silver nitrate. Which of the following nursing interventions should be included for the patient? Standard Text: Select all that apply. 1. Monitor daily weight. 2. Monitor the serum sodium levels. 3. Prepare to change the dressings every two hours. 4. Report black skin discolorations. 5. Push fluid intake.

Correct Answer: 1,2 Rationale: Silver nitrate can cause hypotonicity. Manifestations of hypotonicity include weight gain and edema, which can be monitored by the determination of daily weights. Hyponatremia and hypochloremic alkalosis are common findings in patients treated with silver nitrate so serum sodium and chloride should be monitored. Changing the dressing every two hours is too frequent for the patient. Black discolorations of the skin are anticipated for patients using silver nitrate, and do not highlight a complication of therapy. Silver sulfadiazine, not silver nitrate, administration can result in the development of sulfa crystals in the urine so pushing fluid intake is not an appropriate action for this patient.

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) 1. This is an alkali burn. 2. This type of burn tends to be deeper. 3. This is an acid burn. 4. This type of burn will be easier to neutralize. 5. This type of burn tends to be more superficial.

Correct Answer: 1,2 Rationale: This is an alkali burn which is more difficult to neutralize than an acid burn and tends to have a deeper penetration and be more severe than a burn caused by an acid.

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) 1. Report any fever to your healthcare provider. 2. Report development of purulent drainage to your healthcare provider. 3. Use only sterile dressings on the fingers. 4. Cleanse the areas every hour with alcohol to prevent infection. 5. Apply the topical antimicrobial agent as instructed.

Correct Answer: 1,2,3 Rationale: Fever or purulent drainage are indicative of development of infection and should be reported to the healthcare provider. Sterile dressings only should be used on the areas of the superficial partial-thickness burns where the skin is not intact. Cleansing is necessary no more often than daily to the intact skin areas and only soap and water should be used, not alcohol. Topical agents may be ordered by the health care provider and the patient should follow directions for applying to help prevent infection of the areas.

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. 1. What type of current was involved? 2. How long was the patient in contact with the current? 3. How much voltage was involved? 4. Where was the patient when the burn occurred? 5. What was the point of contact with the current?

Correct Answer: 1,2,3 Rationale: The severity of electrical burns depends on the type and duration of the current and amount of voltage. Location is not important in determining possible severity. Location is not important in determining possible severity.

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) 1. drain cleaners 2. household ammonia 3. oven cleaner 4. toiler bowl cleaner 5. lemon oil furniture polish

Correct Answer: 1,2,3,4 Rationale: All of the products except for the furniture polish can cause burns since they are either alkalis or acids.

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. 1. the depth of the burn 2. extent of burns on the body 3. the causative agent and the duration of exposure. 4. location of burns on the body 5. the time that the burn occurred

Correct Answer: 1,2,3,4 Rationale: Depth of the burn (the layers of underlying tissue affected) and extent of the burn (the percentage of body surface area involved) are used in determining the amount of tissue damage and classification of the burn.The causative agent is especially important with chemical burns such as from strong acids or alkaline agents. The location of the burns on the body is one of the important determinates of classification. For example, burns of the face and hands are always considered major burns. Time of occurrence of the burn is not necessary for classification.

During the acute phase of burn treatment, important goals of patient care include which of the following? Select all that apply. 1. providing for patient comfort 2. preventing infection 3. providing adequate nutrition for healing to occur 4. splinting, positioning, and exercising affected joints 5. assessing home maintenance management

Correct Answer: 1,2,3,4 Rationale: The goals of treatment for the acute period include wound cleansing and healing; pain relief; preventing infection; promoting nutrition; and splinting, positioning, and exercising affected joints. Assessment of home maintenance management is an important goal in the rehabilitative stage, not the acute stage.

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? 1. first-degree burn 2. superficial second-degree burn 3. deep second-degree burn 4. third-degree burn

Correct Answer: 2 Rationale: Partial-thickness, or second-degree, burns can either be superficial or deep. This patient's burn, which appears moist with blisters, is consistent with a superficial second-degree burn. A first-degree burn would involve only the surface layer of skin. Redness would be expected. Deep second-degree and third-degree burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue.

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.

Correct Answer: 2080 mL Rationale : The modified Brooke formula is 2 mL × total kg of body weight × % TBSA. In this situation, 2 mL × 52 kg × 40 = 4160 mL. One-half is given over the first eight hours, or 2080 mL.

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.

Correct Answer: 22.5 Rationale : The anterior trunk has superficial partial-thickness burns and is calculated in TBSA as 18%. The arm has a deep partial-thickness burn and is calculated as 4.5%. The burn on the lower back is superficial and is not calculated in TBSA.

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? 1. normal rest and sleep pattern 2. typical meal pattern 3. if the patient had to change time zones when traveling to the resort 4. if the patient has been sunburned

Correct Answer: 4 Rationale: Sunburns result from exposure to ultraviolet light. Because the skin remains intact, the manifestations in most cases are mild and are limited to pain, nausea, vomiting, skin redness, chills, and headache. The patient has not reported concerns which will support issues with sleep pattern, diet, and travel.

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. Do you need something for pain right now? b. Please stop yelling. I brought dinner as soon as I could. c. I suggest that you get control of yourself. d. You seem upset. I have time to talk if you'd like.

D ~ Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the clients options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

D ~ The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.