417 Exam 1
A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following? a) Stains clothing b) Severe burning pain for up to 20 minutes c) Blood levels of sodium and potassium will be monitored. d) Can be left in place for 3 to 5 days
B
Which of the following measures can be used to cool a burn? a) Using cold soaks or dressings for at least 1 hour b) Application of cool water c) Wrapping the person in ice d) Application of ice directly to burn
B
A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern? a) K+: 5.0 mEq/L b) BUN: 28 mg/dL c) Na+: 145 mEq/L d) Ca: 9 mg/dL
B normal bun 10 - 20
A patient presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following? A 27% B 18% C 36% D 9%
C
A burn patient is brought to the emergency department. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Metabolic acidosis C) Hypovolemia D) Hyperkalemia
A
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient? A) Fluid status B) Risk of infection C) Body image D) Level of pain
A
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis
A
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.
B
During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? a. begin IV fluid replacement b. monitor for signs of complications c. access and manage pain and anxiety d. discuss possible reconstructive surgery
B
During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? a. begin IV fluid replacement b. monitor for signs of complications c. access and manage pain and anxiety d. discuss possible reconstructive surgery
B
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? a. blisters b. reddening of the skin c. destruction of all skin layers d. damage to sebaceous glands
B
The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? a. SQ tetanus toxoid b. IV morphine sulfate c. IM hydromorphone d. PO oxycodone and acetaminophen
B
The patient you are caring for has an electrical burn and has developed thick eschar over the burn wound. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat
B
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction
B
Which of the following is to be expected soon after a major burn? Select all that apply. a) Bradycardia b) Anxiety c) Hypertension d) Hypotension e) Tachycardia
B D E
Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? Colloids Crystalloids Fresh-frozen plasma Packed red blood cells
Crystalloids
A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. obtain vital signs and a STAT ABG b. encourage the patient to cough and auscultate the lungs again c. document the findings and continue to monitor the patient's breathing d. anticipate the need for endotracheal intubation and notify the physician
D
A patient is brought to the ED by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse will complete which of the following interventions first? a) Take the patient's vital signs. b) Obtain a 12-lead ECG. c) Insert a urinary Foley catheter. d) Apply a cervical collar on the patient.
D
A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management
D
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.
D
In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? a. Serum sodium and potassium increase b. Serum sodium and potassium decrease. c. Edema and arterial blood gases improve. d. Diuresis occurs and hematocrit decreases.
D
The nurse is caring for a patient in the burn unit. Which of the following may be an early sign of sepsis in the patient with burn injury? a) Clammy skin b) Decreased pulse rate c) Hyperthermia d) Narrowing pulse pressure
D
All of the following laboratory test results on a burned client's blood are present during the emergent phase. Which result should the nurse report to the physician immediately? Serum sodium elevated to 131 mmol/L (mEq/L) Serum potassium 7.5 mmol/L (mEq/L) Arterial pH is 7.32 Hematocrit is 52%
Serum potassium 7.5 mmol/L (mEq/L)
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis
a
Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.
b
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? a. blisters b. reddening of the skin c. destruction of all skin layers d. damage to sebaceous glands
b. The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
The burned client's family ask at what point the client will no longer be at increased risk for infection. What is the nurse's best response? "When fluid remobilization has started." "When the burn wounds are closed." "When IV fluids are discontinued." "When body weight is normal."
"When the burn wounds are closed."
A client arrives at the emergency department after being rescued from a burning building. Both arms and the entire chest are covered with dry, leathery, charred skin that does not blanch. What is the priority for the client's care? 1. Administration of IV lactated Ringer's 2. Antibiotic administration 3. Incision through the burned tissue (escharotomy) 4. IV administration of analgesics
1
A client has just arrived to the Emergency Department and has sustained burns on the front and back of the right arm and leg. 1. 27% 2. 18% 3. 36% 4. 9%
1
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
1
A client is rushed to the emergency room after having a 500 pound steel container fall onto their left side, spilling hazardous material all over the clients face. The chemical is burning the clients face and the client is losing their airway. The nurse gowns up into the hazmat suit and makes sure it is safe to enter the hazmat room. What is the nurses priority at this time? 1. Maintain the clients airway 2. Pour water over the client and remove all hazerdous material 3. Get a set of vital signs 4. Give the patient oxygen
2
Four clients with different skin alterations come to the emergency department. Which client should the nurse advise that the health care provider (HCP) see first? 1. 8-year-old client who uses corticosteroid inhaler and has white patches on the tongue 2. 50-year-old client who developed a smooth, red, pinpoint rash after taking sulfa 3. 60-year-old client with pain and crusted blisters along the back 4. 70-year-old client who has erythema with a small pustule at the hair follicle
2
A patient has been brought in to the emergency department with 2nd and 3rd degree burns over 40 percent of his body. The effects of the burn on the cardiovascular system include which of the following? Select all that apply. 1. Increased mean arterial pressure 2. Fluid volume deficit 3. ECG changes 4. Hypovolemic shock 5. Myocardial infarction
2 3 4 5
An adult client was severely burned in a warehouse accident. The client has second-degree burns on the right leg and right arm as well as the back. Using the rule of nines, the nurse estimates the percentage of the client's burns as which of these options? 1. 25% 2. 32% 3. 45% 4. 50%
3
The nurse is caring for a client in the intensive care unit who suffered partial-thickness burns to 36% of the body. During the first 24 hours, the nurse would anticipate which of the following assessments? 1. Hemoglobin 10.2 g/dL (102 g/L) 2. Hyperactive bowel sounds 3. Serum sodium 152 mEq/L (152 mmol/L) 4. Tall, peaked T waves on ECG
4
The nurse is caring for an adult client who was hospitalized after a car accident with third-degree burns over 50% of the body. Which solution can the nurse anticipate using for fluid resuscitation? 1. 0.45% normal saline 2. 5% dextrose normal saline 3. 5% dextrose in water 4. Lactated Ringer's
4
The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How will the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.
A
Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? a) Reduction in blood volume b) Sodium excess c) Increased urinary output d) Potassium deficit
A
Which of the following is the preferred IV fluid for burn resuscitation? a) Lactated Ringer's (LR) b) D5W c) Total parenteral nutrition (TPN) d) Normal saline (NS)
A
Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
A
A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)? a. singed nasal hair b. generalized pallor c. painful swallowing d. burns on the upper extremities e. history of being involved in a large fire
A B C E
The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply. a) Heart rate b) Urine output c) Oxygen saturation d) Blood pressure
A B D
A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply . a) "This medication is an antibacterial." b) "This medication will stain my skin permanently." c) "This medication will help my burn heal." d) "This medication will be applied directly to the wound."
A C D
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.
ANS: A The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.
ANS: C The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.
Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have? a) Fourth degree b) Superficial (first degree) c) Full thickness (third degree) d) Superficial partial-thickness and deep partial-thickness (second degree
C
The acute phase of the burn begins 48 to 72 hours after the burn. What begins at this time? A) Cardiac output decreases B) Renal failure begins C) Diuresis D) Fluid moves from intravascular compartment to interstitial spaces
C
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis? a) Fourth degree b) Full-thickness c) Deep partial-thickness d) Superficial partial-thickness
C
Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include: a. adherence of albumin to vascular walls b. movement of potassium into vascular space c. sequestering of sodium and water in interstitial fluid d. hemolysis of red blood cells from large volumes of rapidly administered fluid
C (it describes edema)
The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? Superficial Partial-thickness superficial Partial-thickness deep Full thickness
Full thickness
The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury? Place a towel roll under the client's neck or shoulder. Keep the client in a supine position without the use of pillows. Have the client turn the head from side to side 90 degrees every hour while awake. Keep the client in a semi-Fowler's position and actively raise the arms above the head every hour while awake.
Have the client turn the head from side to side 90 degrees every hour while awake.
The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission? Airway patency Heart rate and rhythm Orientation to time, place, and person Current range of motion in all extremities
Heart rate and rhythm
Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery? Increased urine output, decreased urine specific gravity Increased peripheral edema, decreased blood pressure Decreased peripheral pulses, slow capillary refill Decreased serum sodium level, increased hematocrit
Increased urine output, decreased urine specific gravity
The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action? Raise the head of the bed. Notify the emergency team. Loosen the dressings on the chest. Document the findings as the only action.
Notify the emergency team.
The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? Superficial Partial-thickness superficial Partial-thickness deep Full thickness
Partial-thickness superficial
When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. mannitol 75 gm IV b. urine for myoglobulin c. LR at 25 mL/h d. sodium bicarbonate 24 mEq q.4h
c. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN. Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2-4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin.
A nurse on the burn unit is caring for a patient who has gone into the acute phase of her burn. What would be important for the nurse to monitor the patient for? A) Hypometabolism B) Hyponatremia C) Hyperkalemia D) Hypoglycemia
B
A client who suffered a burn injury has received fluid resuscitation and is now diuresing, indicating the end of the emergency phase. Which prescription is the highest priority at this time? 1. Administer enteral feedings at the return of bowel sounds 2. Assist the client in activities of daily living as tolerated 3. Contact the client's religious advisor for spiritual support 4. Educate the client's family about dressings and medications
1
A client who suffered a burn injury has received fluid resuscitation and is now diuresing, indicating the end of the emergency phase. Which prescription is the highest priorityat this time? 1. Administer enteral feedings at the return of bowel sounds 2. Assist the client in activities of daily living as tolerated 3. Contact the client's religious advisor for spiritual support 4. Educate the client's family about dressings and medications
1
A triage nurse takes a call from a patient who tells her that he has been burned while trying to do some electrical wiring. The nurse asks the client for more information. Which data from the patient would indicate that he has suffered a 2nd-degree burn? 1. The skin is dark red, glossy, and has blisters 2. The skin is light red and swollen 3. The skin is light red with a small amount 4. The skin is dark, leathery, and dry
1
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
1 2 3 4
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and both legs. The burns to the lower legs are circumferential. The nurse knows to monitor closely for what as the edema in this patient increases? A) Ischemia B) Eschar C) Hyper-profusion to the burned area D) Increased fluid loss through the burned area
A
All of the following are antimicrobials commonly used to treat burns except: a) Tetracycline b) Silver sulfadiazine (Silvadene) c) Mafenide (Sulfamylon) d) Silver nitrate (AgNO3) 0.5% solution
A
The nurse is caring for a patient with superficial partial-thickness burn injuries to the lower extremities. The patient is ordered IV morphine for pain. The nurse understands narcotics are given IV to manage pain during the initial management of pain because of which of the following? a) Tissue edema may interfere with drug absorption via other routes. b) The patient can experience nausea and emesis when given oral medications. c) Bleeding may occur at injection sites when the intramuscular route is used. d) Pain resulting from a burn injury requires relief by the fastest route available.
A
The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following? a) Liquid blood component is lost into extravascular space b) Fluid loss c) Decreased renal blood flow d) Sodium and water retention caused by increase adrenocortical activity
A
The nursing instructor is teaching about the emergent/resuscitative phase of burn injury. During this phase, what would the nursing instructor tell the students they should closely monitor in the laboratory values? A) Sodium deficit B) Bleeding time C) Potassium deficit D) Decreased hematocrit
A
Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. a) Facial burns b) Yellow sputum c) Hoarseness d) Singed nasal hair e) Bradypnea
A C D
The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care ()? (select all that apply)? a. escharotomy b. administration of diuretics c. IV and oral pain medications d. daily cleansing and debridement e. application of topical antimicrobial agent
A C D E
When assessing a patient with a partial-thickness burn, the nurse would expect to find (SATA): a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance
A D E
An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings.
ANS: A With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's solution. d. Administer the ordered hydromorphone (Dilaudid).
ANS: A A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.
ANS: C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal.
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light
ANS: C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL
ANS: C Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.
ANS: D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.
Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.
ANS: D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.
The burned client on admission is drooling and having difficulty swallowing. What is the nurse's best first action? Assess level of consciousness and pupillary reactions. Ask the client at what time food or liquid was last consumed Auscultate breath sounds over the trachea and mainstem bronchi Measure abdominal girth and auscultate bowel sounds in all four quadrant
Auscultate breath sounds over the trachea and mainstem bronchi
The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? a. severe pain, blisters, and blanching with pressure b. pain, minimal edema, and blanching with pressure c. redness, evidence of inhalation injury, and charred skin d. no pain, waxy white skin, and no blanching with pressure
D
Which of the following complications is common for victims of electrical burns? a) Inhalation injury b) Infection c) Hypovolemic shock d) Cardiac dysrhythmia
D
Which of the following is the analgesic of choice for burn pain? a) Fentanyl b) Demerol c) Tylenol with codeine d) Morphine sulfate
D
A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness
D
A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? a. 18% b. 22.5% c. 27% d. 36%
b. Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.
