Test 3

Identify in the correct order the five layers of the skin from the surface inward. 1. Stratum granulosum 2. Stratum corneum 3. Stratum germinativum 4. Stratum lucidum 5. Stratum spinosum a. 2, 4, 1, 5, 3 b. 2, 4, 5, 1, 3 c. 4, 2, 5, 1, 3 d. 4, 5, 1, 3, 2

a. 2, 4, 1, 5, 3

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement? a. 5950 mL of Lactated Ringer (LR) solution for the first 8 hours; then 5950 mL of LR over the next 16 hours b. 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic NS over the next 16 hours c. 11,900 mL of dextran evenly divided over the first 24 hours d. 11,475 mL of LR evenly divided over the first 24 hours

a. 5950 mL of Lactated Ringer (LR) solution for the first 8 hours; then 5950 mL of

Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? a. Daily assessment for proper fit and effectiveness b. Removal of splints during showers and dressing changes c. Allowing for frequent breaks from splint use d. Passive and active range of motion may be used instead of splints

a. Daily assessment for proper fit and effectiveness

A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this diagnosis? (Select all that apply, one, some, or all.) a. Epigastric and abdominal pain b. Nausea and vomiting c. Diaphoresis d. Jaundice e. Hyperactive bowel sounds f. Fever

a. Epigastric and abdominal pain b. Nausea and vomiting d. Jaundice f. Fever

A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? a. Escharotomy b. Silver sulfadiazine application c. Splint application d. Xenograft application

a. Escharotomy

A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? a. Intravenous opiates and assessment of pulses in both arms b. Oral antiinflammatory drugs and preparation for insertion of an arterial line c. Measurement of sedimentation rate and systemic antibiotics d. Application of splints and initiation of total parenteral nutrition

a. Intravenous opiates and assessment of pulses in both arms

Which disorders or conditions are potential causes of acute liver failure? (Select all that apply, one, some, or all.) a. Ischemia b. Hepatitis A, B, C, D, E, non-A, non-B, non-C c. Acetaminophen toxicity d. Wilson disease e. Reye syndrome f. Diabetes

a. Ischemia b. Hepatitis A, B, C, D, E, non-A, non-B, non-C c. Acetaminophen toxicity d. Wilson disease e. Reye syndrome

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care? a. Monitor the patient for hypovolemic shock from plasma volume depletion. b. Observe the patient for hypoglycemia and hypercalcemia. c. Initiate enteral feedings after the nasogastric tube is placed. d. Place the patient on a fluid restriction to avoid the fluid sequestration

a. Monitor the patient for hypovolemic shock from plasma volume depletion.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism? a. Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area b. Superficial mucosal erosions because of increased stress levels c. Loss of protective mechanisms resulting in the breakdown the mucosal resistance d. Inflammation and ulceration secondary to nonsteroidal anti-inflammatory drug use

a. Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area

What are the goals of the rehabilitation phase of burn management? a. Recuperation and healing physically and emotionally b. Hydrotherapy and splinting c. Reverse wound isolation and surgical grafting d. Bed rest and splinting

a. Recuperation and healing physically and emotionally

The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? a. Zone of coagulation b. Peripheral zone c. Zone of stasis d. Zone of hyperemia

a. Zone of coagulation

A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What is the best response by the nurse? a. "This procedure is usually performed for cancer of the proximal esophagus and gastroesophageal junction." b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." c. "This procedure is usually performed for cancer of the pancreatic head." d. "The procedure is usually performed for varices of the distal esophagus and gastroesophageal junction."

b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction."

Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and full-thickness burns to half of his left arm, his entire left leg, and his perineum. a. 28% b. 23.5% c. 45.5% d. 16%

b. 23.5%

Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL

b. 5550 mL

A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control? a. Administer analgesics only as needed. b. Administer analgesics around the clock. c. Educate the patient and family on lifestyle changes. d. Teach relaxation and distraction techniques.

b. Administer analgesics around the clock.

A patient is brought to the emergency department after a house fire. The patient sustained an inhalation injury. The nurse is aware that this injury predisposes the patient to the development of what complication? a. Tension pneumothorax b. Adult respiratory distress syndrome (ARDS) c. Asthma d. Lung cancer

b. Adult respiratory distress syndrome (ARDS)

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan? a. Diabetes management b. Alcohol cessation c. Occult blood testing d. Anticoagulation management

b. Alcohol cessation

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? a. Clean the wounds and remove blisters. b. Assess the airway and provide 100% oxygen. c. Place a urinary drainage catheter and assess for myoglobin. d. Place a central intravenous access and provide antibiotics.

b. Assess the airway and provide 100% oxygen.

The nursing management plan for a patient with full-thickness burns includes which intervention? a. Daily replacement of autografts b. Daily wound care with premedication c. Weekly wound care until all eschar is debrided d. Surgical skin grafting within 8 hours of admission

b. Daily wound care with premedication

How would the nurse administer sucralfate through a gastric tube? a. Crushed and mixed with 10 mL of water b. Dissolved in 10 mL of water to form a slurry c. Mixed in 15 mL of water to form a solution d. Administered as a whole pill with a 35-mL water flush

b. Dissolved in 10 mL of water to form a slurry

Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage? a. Positioning the patient in a high-Fowler position b. Ensuring the patient has a patent airway c. Irrigating the nasogastric tube with iced saline d. Maintaining venous access so that fluids and blood can be administered

b. Ensuring the patient has a patent airway

What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure

b. Infection

A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason? a. Infection b. Lack of blood supply c. Lack of lymphatic drainage d. Contamination

b. Lack of blood supply

The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention is the highest priority? a. Preventing atelectasis b. Managing pain c. Promoting ambulation d. Preventing infection

b. Managing pain

A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? a. Superficial, first-degree burn b. Partial-thickness, second-degree burn c. Deep dermal partial-thickness, second-degree burn d. Full-thickness, third-degree burn

b. Partial-thickness, second-degree burn

A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage? a. Stress ulcers b. Peptic ulcers c. Nonspecific erosive gastritis d. Esophageal varices

b. Peptic ulcers

According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that apply, one, some, or all.) a. Arms b. Perineum c. Chest d. Genitalia e. Face

b. Perineum d. Genitalia e. Face

A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply, one, some, or all.) a. Benzodiazepines for agitation b. Pulse oximetry and serial arterial blood gas measurements c. Insulin drip for hyperglycemia and hyperkalemia d. Monitoring electrolyte blood levels e. Assessing for signs of cerebral edema

b. Pulse oximetry and serial arterial blood gas measurements d. Monitoring electrolyte blood levels e. Assessing for signs of cerebral edema

A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? (Select all that apply, one, some, or all.) a. Calcium b. Serum amylase c. Serum glucose d. Potassium e. White blood cells f. Serum triglycerides

b. Serum amylase c. Serum glucose e. White blood cells f. Serum triglycerides

A patient was admitted with acute liver failure. The patient is lethargic, confused, and has marked asterixis. What stage of hepatic encephalopathy is the patient exhibiting? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

b. Stage 2

The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence? a. Crackles in the lung bases b. Subcutaneous emphysema c. Incisional bleeding d. Absent of bowel sounds

b. Subcutaneous emphysema

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the provider to order for this patient? a. Histamine2 (H2) antagonists b. Vasopressin c. Heparin d. Antacids

b. Vasopressin

A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery an RYGBP is. What is the best response by the nurse? a. "It is an esophagectomy performed using the transthoracic approach." b. "It is an esophagectomy performed using a transhiatal approach." c. "It is a combination of restrictive and malabsorption types of bariatric surgery." d. "It is a standard operation for pancreatic cancer."

c. "It is a combination of restrictive and malabsorption types of bariatric surgery."

The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to prevent cross-contamination and decrease the risk of infection in the burn-injured patient? a. Gloves are the only personal protective equipment worn when changing dressings that are in direct contact of body fluids. b. Family members only have to wear a gown when visiting a patient because masks will increase anxiety in the patient. c. Changing gloves and handwashing should be done when moving from area to area on the same patient. d. Sharing of equipment between patients in the same room does not show evidence of cross-contamination.

c. Changing gloves and handwashing should be done when moving from area to area on the same patient.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. Which side effect is the nurse monitoring for? a. Constipation b. Diarrhea c. Chest pain d. Bleeding

c. Chest pain

An older patient reports taking cimetidine for several years. The nurse knows that this medication can cause central nervous system side effects. Which side effect would the nurse monitor the patient for? a. Tremors b. Dizziness c. Confusion d. Hallucinations

c. Confusion

A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record? a. Superficial partial-thickness burn b. Moderate partial-thickness burn c. Deep dermal partial-thickness burn d. Full-thickness burn

c. Deep dermal partial-thickness burn

The nurse is caring for a patient with acute liver failure. The provider asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom? a. Inflate a blood pressure cuff on the patient's arm. b. Have the patient bring the knees to the chest. c. Have the patient extend the arms and dorsiflex the wrists. d. Dorsiflex the patient's foot.

c. Have the patient extend the arms and dorsiflex the wrists.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan? a. Continue as planned; everything looks good. b. IV rate should be decreased and colloids started. c. IV rate should be increased and fluid status closely watched. d. Fluids should be switched to packed red blood cells.

c. IV rate should be increased and fluid status closely watched.

The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the provider to order for this patient? a. Insulin b. Vitamin K c. Lactulose d. Lorazepam

c. Lactulose

What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.

c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space.

A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury? a. Rhabdomyolysis b. Stress ulcers c. Pneumothorax d. Venous thromboembolism

c. Pneumothorax

A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs because of what pathophysiologic mechanism? a. Uncontrolled hypoglycemia caused by an increased release of insulin b. Loss of storage capacity for senescent red blood cells c. Premature activation of inactive digestive enzymes, resulting in autodigestion d. Release of glycogen into the serum, resulting in hyperglycemia

c. Premature activation of inactive digestive enzymes, resulting in autodigestion

A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen? a. Allows for administration of tube feeding b. Allows for testing of gastric secretions c. Prevents the tube from adhering to the gastric wall d. Prevents the tube from advancing

c. Prevents the tube from adhering to the gastric wall

A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing, which is characterized by rapid synthesis of collagen. What phase is the patient in? a. Wound phase b. Inflammatory phase c. Proliferative phase d. Maturation phase

c. Proliferative phase

The nurse and a new graduate nurse are caring for a patient with extensive burns and are discussing skin grafts. Which statement indicates the new graduate understood the information? a. "Autografts are procured from both live and deceased donors." b. "Autografts can be placed at the bedside or in the operating room." c. "Autografts can transmit disease and be rejected." d. "Autografts provide permanent coverage and are the least expensive."

d. "Autografts provide permanent coverage and are the least expensive."

A patient has been admitted with severe abdominal pain. When examining the patient, the nurse notes hypoactive bowel sounds, abdominal guarding, distention, and a discoloration around the umbilicus. The nurse suspects the patient may have which condition? a. Peptic ulcer disease b. Esophageal varices c. Acute liver failure d. Acute pancreatitis

d. Acute pancreatitis

A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% high-flow oxygen via a nonrebreathing mask

d. Administer 100% high-flow oxygen via a nonrebreathing mask

Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? a. Uncontrolled pain b. Hypovolemia c. Worsening hypoxemia d. Decreased pulmonary compliance

d. Decreased pulmonary compliance

A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms? a. Metabolic acidosis and hypovolemia b. Decreasing hemoglobin and hematocrit c. Hyperkalemia and hypernatremia d. Hematemesis and melena

d. Hematemesis and melena

Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria? a. Pure silver b. Bacitracin c. Mafenide acetate cream d. Silver sulfadiazine

d. Silver sulfadiazine

A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery? a. Large doses of opioids given intramuscularly b. Intravenous opioids used in combination with oral antidepressants c. Large doses of opioids given subcutaneously d. Small doses of intravenous opioids titrated to effect

d. Small doses of intravenous opioids titrated to effect

A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center? a. The size and depth of burn injury and the burning agent b. The age and present medical history of the patient c. The depth of the burn injury and the presence of soot in the sputum d. The medical history of the patient and the size and depth of the burn injury

d. The medical history of the patient and the size and depth of the burn injury

Roughly 80% of burns in children are classified as what type of burn? a. Radiation b. Chemical c. Electrical d. Thermal

d. Thermal

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable to what cause? a. Blood loss associated with burns and pain b. Hemodynamic stability related to adequate fluid resuscitation. c. Overresuscitation related to overestimation of the burn area involved d. Underresuscitation because of probable wound conversion

d. Underresuscitation because of probable wound conversion