BURNS TEST 3/Lippencott/priority & new priority

1 (TPN cannot be touched)

NP I CS 9) Which action by the UAP warrants intervention by Ms. Glada? 1. The UAP decreases the IV rate of the client whose TPN is almost empty 2. The UAP elevates the HOB for a client receiving continuous tube feeding 3. The UAP assists the client with full-thickness burns to the UE to eat a high protein meal 4. The UAP mixes Thick-It into the glass of water for the client who has difficulty swallowing

4 (The electrical current in the body bounces off bone and goes through muscle. The heart is a muscle; therefore the priority intervention is for the nurse to apply cardiac monitors to assess for lethal dysrhythmias that may occur. WRONG: #1 The wounds need to be kept sterile to decrease the chance of infection, but not priority #2 The clients need VS assessed, but priority with electrical is cardiac monitoring #3 The clients o2 should be monitored but not priority with electrical /cardiac)

PD 54 I) The client with an electrical burn is brought to the ED The entrance wound is on the R hand and the exit wound is on the L foot. Which intervention should the nurse implement first? 1. Place sterile gauze on the entrance and exit wounds 2. Assess the clients VS 3. Monitor the pulse oximetery 4. Place the client on cardiac telemetry

1,2,5 (HAndwashing is the #1 intervention to prevent infection. The client is at risk for infections and visitors with infections should not be allowed to visit. Prophylactic antibiotics are administered to help prevent infection. WRONG: #3 The client MUST have high protein diet to help with tissue growth. #4 Invasive lines and tubing shoud be changed daily)

PD CS 4) Which nursing intervention should be included for the client who has full thickness and deep partial thickness burns to 50% of the body? SATA 1. Perform meticulous hand hygiene 2. Screen visitors for infections 3. Provide low cholesterol,, low protein diet 4. Change invasive lines once a week 5. Administer prophylactic antibiotics as prescribed

3 (Deep unrelenting pain is a sign of compartment syndrome, an acute, potentially life threatening complication,, in a client with a fracture; therefore this client should be assigned to the most experienced nurse)

PD I 18) The charge nurse on the acute care rehab unit is making assignments for the shift. Which client should the charge nurse assign to the most experienced nurse? 1. The client with full thickness burn who is refusing to go to therapy 2. The client with osteomyelitis who has bone pain and fever 3. The client with fractured tibia who has deep unrelenting pain 4. The client with low back pain radiating down the left leg

3 (Ensuring a urine output of 30-50 ml/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The BP is low, likely related to hypovolemia, but the urinary output is he more accurate indicator of fluid balance and kidney function. The Na is wnl)

5. The nurse is caring for a client with severe burns who is receiving fluid resuscitation, Which finding indicates that the client is responding to the fluid resuscitation? 1. pulse rate of 112 bpm 2. BP of 94/64 3. urine output of 30 mL/hr 4 serum sodium level of 136

3 (Clients should be turned every 1-2 hrs to prevent pressure areas WRONG: #2 The UAP is not responsible to ensure pain intervention is implemented)

NP I CS 8) Ms Glada is teaching a group of new UAPs about burn care Which information regarding skin care should Ms. Glada emphasize? 1. Keep the skin moist by leaving the skin damp after the bath 2. Ensure the client is premedicated prior to the whirlpool 3. Tell the UAP to turn the client side to side at least every 2 hrs 4. Instruct the UAP to not implement any intervention regarding skin care

2 (Deep partial thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin and edema. WRONG: #1 Sunburn is an example of superficial partial thickness burns which affect the epidermis and the skin is reddened and blanches with pressure. #3 Full thickness burns are caused by flame, electrical current, or chemicals, and include the epidermis, entire dermis, and sometimes the subcutaneous tissue, and may also involve connective tissue, muscle and bone. #4 First degree burn is another name for superficial partial-thickness burn)

PD IS 1) The male client is admitted to the burn unit after a boiling pot of hot water accidentally spilled on his lower legs. The assessment reveals blistered mottled red skin and both feet are edematous. Which depth burn should George document? 1. Superficial partial thickness 2. Deep partial thickness 3. Full thickness 4. First degree

3 (A child with moderate burns is at high risk for contracture. A position of comfort would encourage contracture formation. Therefore splints need to be applied to maintain proper positioning and joint function. Thereby preventing contractures and loss of function. Allowing the child to lie on the abdomen or with the hips and knees flexed often encourages contracture formation.)

When caring for a child with moderate burns from the waist down, what should the nurse do when positioning the client? 1. place the child in a position of comfort 2. Allow the child to lay on the abdomen 3. Ensure the application of leg splints 4. Have the child flex the hips and knees

2 4 1 3 (The nurse should first attempt to determine exactly when and how much tylenol the parents think the child has taken. Determining the time of ingestion helps establish the immed care and when lab values should be drawn, Gastric decontamination with activated charcoal is used within 4 hrs of ingestion to bind the drug and help prevent toxic serum levels. Serum blood levels should be done after the gastric decontamination, but preferably not too soon after ingestion since levels drawn before the 4 hrs may not reflect maximum serum concentrations and will need to be repeated. The decision to administer acetylcysteine and prevent liver damage is based on serum levels)

The parent of a 3 year old suspect that the child recently ingested a large amount of tylenol. The child does not appear in immed. distress. The nurse should anticipate doing which interventions in order of priority, from first to last? 1. draw acetaminophen serum levels 2. attempt to determine the exact time and amount of drug ingested 3. administer acetylcysteine IV 4. administer activated charcoal

4 (Analgesic admin is to keep a burn victim comfortable and is important, but is unlikely to influence graft survival and effectiveness. Absence of infection, adequate vascularization, and immobilization of the grafted area promote an effective graft)

9. Which factor would have the least influence on the survival and effectiveness of a burn victims porcine grafts? 1. absence of infection in the wounds 2. adequate vascularization in the grafted area 3. immobilization of the area being grafted 4. use of analgesics as necessary for pain relief

1,2,3 (Clients who should be transferred to a burn center include children under the age of 10 or adults over the age of 50 with second- and third- degree burns on 10% or greater of their BSA. Clients between ages 11-49 with second- and third- degree burns of 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA and clients with smoke inhalation, and clients with chronic diseases such as diabetes and heart and kidney disease)

1 There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? SATA 1. an 8 year old with third degree burns over 10% of the body surface area 2. a 20 year old who inhaled the smoke of the fire 3. A 50 year old diabetic with first and second degree burns on the left forearm (about 5% of the body surface area) 4. A 30 year old with second degree burns on the back of the left leg (about 9% of the BSA) 5. A 40 year old with second degree burns on the R arm (about 10% BSA)

3 (The decrease urine output, low BP, low CVP, and a high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given with FVD. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is LR, NS or albumin.)

13 A client is receiving fluid replacement with lactated Ringers after 40% of the body was burned 10 hrs ago. The assessment reveals temperature 97.1 (36.2 C) HR 122, BP 84/42, central venous pressure (CVP) 2 and urine output 25 mL/hr for the last 2 hours Using the SBAR technique for communication, the nurse calls the HCP with recommendation for: 1. furosemide 2, fresh frozen plasma 3. IV rate increase 4. dextrose 5%

750 (When calc fluid replacement only use the burned portion of the TBSA. HALF given over 1st 8 hrs. and 1/2 given over next 16 hrs. LR 4 mL x wt in kg x TBSA STep one: 4 x 75 x 40= 12000 mL Step two : 12000/ 8 x 1/2 = 750 mL/hr)

18 Using the Parkland formula calculate the hourly rate of fluid replacement with LR solution during the first 8 hrs for a client weighing 75 kg with a TBSA (total body surface area) burn of 40%. Record your answer using a whole number ___________ mL/h

2 ( Dairy products inhibit the absorption of doxycycline, so this action would decrease the effectiveness of the antibiotic. The other activities are not appropriate but would not cause as much potential harm as the administration of doxycycline with milk. Anaerobic bacteria would not be likely to grow in a superficial wound. The herpes zoster vaccine is recommended for clients who are 60 years or older. Pressure garments may be used after graft wounds heal and during the rehabilitation period after a burn injury, but this should be discussed when the client is ready for rehabilitation, not when the client is admitted. Focus: Prioritization)

20. As charge nurse, you are providing orientation for a newly-hired RN. Which action by the new RN requires the most immediate action? 1. Obtaining an anaerobic culture specimen from a superficial burn wound 2. Giving doxycycline (Vibramycin) with a glass of milk to a client with cellulitis 3. Discussing the use of herpes zoster vaccine with a 25-year-old client 4. Teaching a newly admitted burn client about the use of pressure garments

1 (Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increased serum creatinine. Urine output should be frequently monitored and adequately maintained with IV fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the clients response by monitoring urine output, VS, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to the output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5)

3 During the emergent (resuscitative ) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? 1 serum creatinine level of 2.5 mg 2. little fluctuation in daily weight 3. hourly urine output 60 mL 4. serum albumin level of 3.8

2 ( Facial burns are frequently associated with airway inflammation and swelling, so this client requires the most immediate assessment. The other clients also require rapid assessment or interventions, but not as urgently as the client with facial burns. Focus: Prioritization)

3. You have just received a change-of-shift report for the burn unit. Which client should you assess first? 1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. Client who has just arrived from the emergency department with facial burns sustained in a house fire 3. Client who has just been transferred from the postanesthesia care unit after having skin grafts applied to the anterior chest 4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

3 (According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9% The right leg is 18% and the anterior trunk is 18% for a total of 45%)

4. A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm from hand to just below shoulder, and right leg from thigh to toes. Using the "rule of nines" estimate what percentage of the clients BSA has been burned? 1 18% 2 27 % 3 45% 4. 64%

3 4 2 1 5 ( Pain medication should be administered before changing the dressing, because changing dressings for partial-thickness burns is painful, especially if the dressing change involves removal of eschar. The wound should be debrided before obtaining wound specimens for culture to avoid including bacteria that are skin contaminants rather than causes of the wound infection. Culture specimens should be obtained prior to the application of antibacterial creams. The antibacterial cream should then be applied to the area after débridement to gain the maximum effect. Finally, the wound should be covered with a sterile dressing. Focus: Prioritization)

4. You are performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care plan in the order in which each should be accomplished. 1. Apply silver sulfadiazine (Silvadene) ointment. 2. Obtain specimens for aerobic and anaerobic wound cultures. 3. Administer morphine sulfate 10 mg IV. 4. Debride the wound of eschar using gauze sponges. 5. Cover the wound with a sterile gauze dressing.

3 (Call the pharmacy)

49 The nurse is to administer an antibiotic to a client with burns, but there is no medication in the clients medication box. What should the nurse do first? 1. Inform the units shift coordinator 2. Contact the HCP 3. Call the pharmacy dept 4. Borrow the medication from another client

3 ( A nurse from the oncology unit would be familiar with dressing changes and sterile technique. The charge RN in the burn unit would work closely with the float RN to provide partners to assist in providing care and to answer any questions. Admission assessment and development of the initial care plan, discharge teaching, and splint positioning in burn clients all require expertise in caring for clients with burns. These clients should be assigned to RNs who regularly work on the burn unit. Focus: Assignment)

5. You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit? 1. 23-year-old who has just been admitted with burns over 30% of the body after a warehouse fire 2. 36-year-old who requires discharge teaching about nutrition and wound care after having skin grafts 3. 45-year-old with infected partial-thickness back and chest burns who has a dressing change scheduled 4. 57-year-old with full-thickness burns on both arms who needs assistance in positioning hand splints

2 (Biological dressings such as porcine grafts, serve many purposes for a client with severe burns. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth of subcutaneous tissue)

8. An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: 1. encourage the formation of tough skin 2. promote growth of epithelial tissue 3. provide for permanent wound closure 4. facilitate the development of subcutaneous tissue

3 (Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and NOT one-half hour before hand)

6. At about one half hour BEFORE the daily whirlpool bath and dressing change, the nurse should: 1. soak the dressing 2. remove the dressing 3. administer an analgesic 4 slit the dressing with blunt scissors

250 (2000 mL / 8h = 250 mL)

A school age child who has received burns over 60% of his body is to receive 2000 mL of IV fluid over the next 8 hours. At what rate should the nurse set the infusion pump? Round your answer to a whole number? ____________ mL/hr

2 (The priority intervention in the first 24 hrs is for the client with third degree burn is maintaining intravascular volume so the client will not die from hypovolemic shock. WRONG: #1 The environment should be maintained, but priority is fluid volume. #3 infection prevention is important, but FV is priority. #4 Pain should be assessed but for a client with 3rd degree burns over both legs fluid volume is priority)

PD I 61) The client admitted to the ED with a third-degree burn over the front of both legs. Which priority intervention should the nurse implement? 1. maintain a sterile environment when caring for the client 2. Insert two large-bore IV access routes 3. Admin IV antibiotic therapy 4. Assess the clients pain level on a 1-10 scale

1,2,4

PD I 63) The nurse is discussing alternative medication (CAM) with a client on the rehab unit. Which therapies should the nurse discuss with the client? SATA 1. acupuncture 2. guided imagery 3. compression sequential devices 4. music therapy 5. muscle strengthening exercises

2 (expressions of anger and combativeness are often the result of loss of control and a feeling of powerlessness. Some control over the situation is regained by allowing the child to participate in care. Although having parental support during the dressing changes may be helpful, this action does nothing to give the child control. Giving the child permission to cry may help with verbalizing feelings, but doing so does nothing to provide the child with control. Although allowing the child to schedule the time for dressing changes may provide a sense of control over the situation, doing so is inappropriate because the dressing changes need to be performed as prescribed to ensure effectiveness and healing)

Which interventions would be most appropriate to institute when a school-aged child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate? 1. Ensure parental support during the dressing changes 2. Allow the child to assist in removing the dressings and applying the cream 3. Give the child permission to cry during the procedure 4. Allow the child to schedule the time for the dressing changes

4 (chemical pneumonitis is the most common complication of ingestion of hydrocarbons, such as kerosene. The pneumonitis is caused by irritation from the hydrocarbons aspirated into the lungs. Uremia is a result of renal insufficiency. which causes nitrogenous wastes to build up in the blood rather than being excreted. Carditis in a preschooler may be result of rheumatic fever. Hepatitis is a result of viral infection)

While assessing a preschooler brought by her parents to the ED after ingestion of kerosene, the nurse should be alert for which complication? 1. uremia 2. hepatitis 3. carditis 4. pneumonitis

3 (oxygen must be administered to treat hypoxia, which occurs after a fat embolism, therefore this is the first intervention)

PD I 53) Which intervention should the nurse implement first for the client with a fractured femur who is suspected of having a fat embolism? 1. Assess the clients bilateral breath sounds 2. Encourage the client to cough and deep breathe 3. admin o2 via nc 4. Prepare to admin Iv heparin therapy

2 (Rehab efforts are implemented as soon as the clients condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure the client will be able to make the adjustments necessary to return to optimal status of health and independence. It is not possible to completely eliminate the clients pain. pain control is a challenge in burn care.)

10. The nurse should plan to begin rehabilitation efforts for the burn client: 1. immediately after the burn occurred 2. after the clients circulatory status has been stabilized 3. after grafting of the burn wounds has occurred 4. after the clients pain has been eliminated

4 (Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as the result of loss of sodium bicarb HCO3)

11 During the early phase of burn care, the nurse should assess the client for: 1. hypernatremia 2. hyponatremia 3. metabolic alkalosis 4. hyperkalemia

2 (Airway management is the priority in caring for a burn client. Tracheostomy or ET intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1-2 hours. Electrical burns on the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. SEcondhand smoke inhalation does influence an individual respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke)

12 Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has: 1. electrical burns of the hands and arms causing arrhythmias 2 thermal burns to the head and face and airway resulting in hypoxia 3. chemical burns of the chest and abdomen 4. secondhand smoke inhalation

2 (2 With chemical injuries, it is important to remove the chemical from contact with the skin to prevent ongoing damage. The other actions also should be accomplished rapidly; however, rinsing the chemical off is the priority for this client. Focus: Prioritization)

15. A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is admitted to the ED. Which ordered intervention will you implement first? 1. Infuse lactated Ringer's solution at 250 mL/hr. 2. Rinse the back and legs with 4 L of sterile normal saline. 3. Obtain blood for a complete blood count and electrolyte levels. 4. Document the percentage of total body surface area burned.

2 (During the first 24 hrs fluid replacement for the adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight. Total surface area is estimated by taking into account the individuals height and weight. Height is not a common variable used in formulas for fluid replacement)

15. The rate at which IV fluids are infused is based on the burn clients: 1. lean muscle mass and BSA burned 2. total body weight and BSA burned 3. total BSA and BSA burned 4. height and weight and BSA burned

3 (To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues and decreases fluid loss, and decreases BP, and thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling If only the arm is burned, a call to 911 for emergency care is not necessary But the mother should seek healthcare services immed.)

A 10 year old has just spilled hot liquid on his arm, and a 4 inch (10 cm) area on his FA is severely burned. His mother calls the ED What should the nurse advise the mother to do? 1. Keep the child warm 2. Cover the burned area with antibiotic cream 3. Apply cool water to the burned area 4. Call 911 to transport the child to the hospital

2 (Withholding certain foods until the child complies is punitive and rarely successful. Allowing the mother to feed the child, serving smaller and more freq meals and offering finger foods are all acceptable interventions for a 5 year old child. This is true whether the child is well or ill)

A 5 year old with burns on the trunk and arms has no appetite. The nurse and the parent develop a plan of care to stimulate the childs appetite. Which suggestion made by the parent would indicate the need for additional teaching? 1. deciding that she will feed the client herself 2. withholding dessert and treats unless meals are eaten 3. offering the child finger foods that the child likes 4. serving smaller and more frequent meals

2 (drain cleaner almost always contains lye. Which can burn the mouth, pharynx, and esophagus on ingestion. The nurse would be prepared to assist with procedures to secure the airway, which may include intubation or performing a tracheostomy. An emetic is contraindicated because as the substance burns on ingestion it will burn when vomiting and could lead to perforations. Gastric lavage is contraindicated because the mucosa is burned from the ingestion of the caustic lye, causing necrosis. Gastric lavage also could lead to perforation of the necrotic mucosa. Insertion of an indwelling cath would be indicated after the measures to remove the caustic substance have been started.)

A toddler is brought to the ED after ingesting an undetermined amount of drain cleaner. The nurse should first expect to assist with which intervention first? 1. administering an emetic 2. securing the airway 3. performing gastric lavage 4. inserting an indwelling urinary Foley catheter.

1 (After airway the most urgent need is preventing irreversible shock by replacing Fluids and Electrolytes WRONG: #2 This is important, but not priority over FV. Curlings Ulcer is an acute peptic ulcer of the duodenum resulting as a complication from severe burns when reduced plasma volume leads to sloughing of the gastric mucosa. #3 PRevention of infection is a priority but not prior to maintaining F&E for the first 48-72 hrs. The client will die if F&E is not maintained. #4 An escharotomy, an incision that releases the scar tissue, prevents the body from being able to expand and enables chest excursion in circumferential chest burns. The client has not had time to develop eschar.)

PD I CS 2) Mr Rob is caring for a client who experienced a full thickness burn to 65% of the body 12 hrs ago. After establishing a patent airway, which intervention is priority for the client? 1. Replace the clients fluids and electrolytes 2. Prevent the client from developing Curlings ulcers 3. Implement intervention to prevent infection 4. Prepare to assist with an escharotomy

4 (Curlings Ulcer or GI ulceration occurs in about half of clients with a burn injury. The incidence of ulceration appears proportionate to the extent of burns, and the ulceration is believed to be caused by hypersecretion of gastric acid and compromised GI perfusion. PAralytic ileus. and gastric distension do not result from hypersecretion of gastric acid and stress and thus are not expected at this time. Hiatal hernia is not necessarily a potential complication of a burn injury)

16 The nurse is conducting a focused assessment of the GI system of a client with a burn injury. The nurse should assess the client for : 1. paralytic ileus 2. gastric distension 3. hiatal hernia 4. Curlings ulcer

3 (As the burn from the lye ingestion heals, scar tissue develops and can lead to esophageal strictures, a common complication of lye ingestion. Tracheal stenosis would occur if the child had vomited or aspirated. Tracheal varices do not commonly occur after the ingestion of lye or other substances, Although very rare, esophageal diverticula may occur. Diverticula are commonly found in the colon of adults)

After the acute stage following an ingestion of drain cleaner by a child, the nurse should be alert for the development of which likely complication? 1. tracheal stenosis 2. tracheal varices 3. esophageal strictures 4. esophageal diverticula

2 (The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous birth. The 10 year old is not at risk for infection and could be treated outpatient. First degree burns are considered less urgent)

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? 1. A woman who is 5 months pregnant with no apparent injuries 2. A middle aged man with no injuries who has rapid RR and coughs 3. A 10 year old with a simple fracture of the humerus who is in severe pain 4. A 20 year old with first degree burns on her hands and forearms

3 (When determining which client, Airway is first)

NP I CS 10) Ms Glada is caring for clients on a burn unit. AFter the shift report which client should Ms. Glada assess first? 1. The client with full and deep partial-thickness burns who has pain rated 8 on 1-10 scale 2. The client with full thickness burns who has a urinary output of 120 mL: in the last 8 hrs 3. The client with full thickness burns on the chest who is having difficulty breathing 4. The client who has full thickness burns to the R leg with no palpable pedal puse

5 3 1 2 4 (5. The gait belt is applied to ensure safety 3. The client should use the strong hand to control the assistive device 1. The client should move the cane forward to provide stable support for the weaker leg when it is moved 2. The client should move the weaker leg even with the supportive cane while maintaining the stronger leg in place 4. Finally the stronger leg can move to a position even with the weak leg and can)

PD I 51) The nurse is assisting the client to use a cane when ambulating. Rank in order of performance the interventions the nurse would take: 1. REquest the client move the cane forward 2. Move the weaker leg one step forward 3. Ensure the client places the cane in the strong hand 4. Move the stronger leg one step foreard 5. Apply a gait belt around the clients waist

2

PD I 60) The nurse is caring for a client dx with full-thickness burns over the RLE. Which task should the nurse delegate to the UAP? 1. Instruct the UAP to check the clients right dorsal pedal pulse 2. Ask the UAP to cleanse the clients dentures and place in the container 3. Request the UAP to perform passive ROM 4. Tell the UAP to keep the clients leg in the dependent position

1 (ORthostatic hypotension is a side effect of BB meds, therefore this should be questioned)

PD I 62) The day nurse is preparing to admin medications to the client who is complaining of light-headedness when getting out of bed. Which medication should then day nurse question administering? 1. Atenolol 0900 50 mg PO qd 2. Ceftriaxone (Rocephin) 150 mg 0900 IVPB 3. Bisacodyl (Dulcolax) 2 PO PRN constipation 4. Admin all meds as ordered

1 ( Systemic use of tetracycline is associated with severe photosensitivity reactions to ultraviolet light. All individuals should be taught about the potential risks of overexposure to sunlight or other ultraviolet light, but the client taking tetracycline is at the most immediate risk for severe adverse effects. Focus: Prioritization)

10. You are preparing to discharge four clients from the hospital and are planning their discharge teaching. Which client will it be most important to instruct about the need to use sunscreen? 1. 32-year-old with a urinary tract infection who is being discharged with a prescription for tetracycline (Sumycin) 2. Fair-skinned 55-year-old who has just had neck surgery and who plans to walk in the yard for 15 minutes twice daily 3. Dark-skinned 62-year-old who has had keloids injected with hydrocortisone (Solu-Cortef) 4. 78-year-old with a red, pruritic rash caused by an allergic reaction to penicillin (Bicillin)

3 (The inflammatory response begins when a burn is sustained. As a result of the burn the immune system becomes impaired. There are a decrease in immunoglobulins, changes in WBC, alterations of lymphocytes and decreased levels of interleukin The human bodys protective barrier, the skin, has been damaged. As a result the body is open to infections. Education and interventions to maintain a positive self concept would be appropriate in the rehabilitation phase. Promoting hygiene helps the client feel comfy, however the primary concern is reducing risk for infection)

14. After the initial phase of the burn injury, the clients plan of care will focus primarily on: 1. helping the client maintain a positive self concept 2 promoting hygiene 3. preventing infection 4. educating the client regarding care of the skin grafts

3 (The nurse should have the client transported to a burn center The clients age and the extent of the burns require care by a burn team, and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time)

2 The nurse is assessing an 80 year old client who has scald burns on the hands and both forearms (first and second degree burns on 10% of the BSA) What should the nurse do first? 1. Clean the wounds with warm water 2. Apply the antibiotic cream 3. Refer the client to a burn center 4. Cover the burns with a sterile dressing

4 (Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein thru injured capillaries and an increased metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by IV fluids. Although TPN typically includes all the necessary electrolytes. REsting the GI tract may help prevent paralytic ileus, and TPN provides vitamins and minerals however starting TPN is to provide the protein necessary for tissue healing)

7. The client with major burn injury receives TPN. The expected outcome is to: 1. correct water and electrolyte imbalances 2. allow the GI tract to rest 3. provide supplemental vitamins and minerals 4. ensure adequate caloric and protein intake

1 ( A blue color or cyanosis may indicate that the client has significant problems with circulation or ventilation. More detailed assessments are needed immediately. The other data may also indicate health problems in major body systems, but potential respiratory or circulatory abnormalities are the priority. Focus: Prioritization)

7. Which assessment finding calls for the most immediate further assessment or intervention? 1. Bluish color around the lips and earlobes 2. Yellow color of the skin and sclera 3. Bilateral erythema of the face and neck 4. Dark brown spotting on the chest and back

2 (The severe pain experienced by burn clients requires opioid analgesics. In addition, opioids such as morphine sedate and alleviate apprehesion. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be strong enough to manage the intense pain. Because of the altered tissue perfusion from the burn injury IV meds are preferred. Antianxiety meds are not effective against pain)

17 In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? 1. oral analgesics such as ibuprofen or acetaminophen 2. IV opioids 3. IM opioids 4 oral antianxiety agents such as lorazepam

1 (Hypoproteinemia is common after severe burns. The childs diet should be high in protein to compensate for protein loss and to promote tissue healing. The child will also require a diet that is high in calories and rich in iron. The menu of BLT milk, and celery sticks is lacking in sufficient protein and calories)

After teaching a parent of a child with severe burns about the importance of a specific nutritional support in burn management, which selection of foods, if chosen by the parent from the childs diet menu, indicate the need for further instruction? 1. BLT, milk, celery and carrot sticks 2. Cheesburger, cottage cheese and pineapple salad, chocolate milk and brownie 3. Chicken nuggets, orange and grapefruit sections and vanilla milkshake 4. Beef bean and cheese burrito, a banana, fruit flavored yogurt, and skim milk.

4 (the client with urticaria (hives) and pruritis (itching) is having some type of allergic reaction and should receive the antihistamine first. WRONG: #1 The NSAID is routine, not priority. #2 IV antibiotic is needed but not priority over acute problem #3 The antiviral should be given but not priority over acute problem)

PD I 5) The nurse is preparing to administer morning medications to the following clients, Which medication should the nurse administer first? 1. The NSAID to the client dx with osteoarthritis 2. The IV antibiotic to the client with cellulitis 3. The antiviral agent to the client with herpes zoster (shingles) 4. The antihistamine to the client with urticaria and pruritus

1 (The nurse should implement the first intervention ensuring the client does not move the leg, because doing so can cause further injury. The client should not attempt to move or stand on the injured extremity WRONG: #2 The client should elevate the leg to decrease edema but its not the first intervention. #3 The application will help decrease edema and pain, but is not first. #4 Assessment is usually the first intervention at the scene of an accident but first the nurse should ensure the client does not cause further harm or injury prior to assessing)

PD I 7) The nurse is at a local playground and her 10 year old son falls and complains of his left ankle and foot hurting. Which intervention should then nurse implement first at the scene of the accident? 1. Instruct her son not to move the left leg 2. Elevate the leg on two rolled towels 3. Apply an ice pack to the L ankle 4. Check her sons pedal pulses bilaterally

3 1 5 2 4 (3. This pt has a CHANGE IN NORM sputum production, freq pts dx with obstructive pulmonary diseases are placed on steroid therapy which can mask an infection. 1. This pt has a deep wound that needs assessed 5. This test can be performed by the nurse with a portable machine. The HCP may need to adjust the pts medication based on the results 2. This is a medication to increase the pts WBC production 4. This is expected behavior for a client with Alzheimer's disease)

PD I 70) The home health nurse is planning to make rounds for the day. List in order the clients should be seen by priority: 1. The 20 year old client dx with SCI post MVA who needs a dressing changed on a stage IV pressure area 2. The 56 year old client dx with breast cancer who needs an injection of filgrastim (Neupogen) sc 3. The 67 year old client dx with emphysema who called to report that the sputum is rusty color this morning 4. The 80 year old client diagnosed with Alzheimer's disease who is confused and wandering around the house 5. The 72 year old client dx with atrial fibrillation who needs prothrombin time performed and called to the HCP

4 (Dressing changes for a STage III will be painful for the client and pain meds should be given AT LEAST 30 mins prior to the procedure. )

PD I 8) The nurse is preparing to change a dressing on an 82 year old client with a Stage III pressure ulcer. Which intervention should then nurse implement first? 1. OBtain the needed equipment to perform the procedure 2. Remove the clients old dressing with nonsterile gloves 3. Explain the procedure to the client in understandable terms 4. Check to determine whether the client has received pain medication

1 (The H/H is low which requires the nurse assess this client frist. The nurse must take VS, check the dressing and determine whether the client is symptomatic for hypovolemia. The other s/s are expected for the conditions)

PD I 9) Which client should the charge nurse on the rehab unit assess first after receiving the am shift report? 1. The client dx with an open reduction and internal fixation (ORIF) of the right hip who has a hgb and hct (H/H) of 8/24 2. The client dx with RA who has a positive rheumatoid factor 3. The client dx with stage IV pressure ulcer who has a WBC of 14000 4. The client dx with systemic allergies on prednisone dose pack who has a glucose level of 189

4 (The UAP is a vital part of the team and should be encouraged to attend the multidisciplinary team meeting to provide input into the clients care. WRONG: #1 the UAP cannot teach the client. #2 The client is confused and should be assessed prior to being placed in an inclusion bed, which is used when a client wanders. #3 The UAP cannot admin meds)

PD I 20) Which task should the rehab nurse delegate to the UAP? 1. Tell the UAP to show a client how to perform a self cath 2. Ask the UAP to place the newly confused client in the inclusion bed 3. Request the UAP give the client 30 mL of Maalox an antacid 4. Encourage the UAP to attend the multidisciplinary team meeting

1 (Vanc trough every 3rd or 4th dose depending on HCP order)

PD I 66) The nurse is administering medication to a client with third-degree burns on the chest area. Which medication required a laboratory test? 1. Vancomycin IVPB 500 mg qd 2. Protonix 40 mg IVPB qd 3. Silvadene topical ointment to burn tid 4. Morphine 2-5 mg IVP PRN pain

2 (A pulse ox reading greater than 93% is wnl Therefore a 90% indicates respiratory distress. WRONG: #1 pain would be expected, #3 The VS show elevated T, HR, RR, along with Low BP, but these are not unusual for client with severe burns. #4 F&E must be evaluated to ensure output is 30mL/hr but this is wnl.)

NP I CS 6) Mr. Rob is caring for a cliet with deep partial thickness and full-thickness burns to the chest area. Which of the following assessment data warrant notifying the HCP? 1. The client is complaining of pain rated 9 on 1-10 scale 2. The clients pulse oximeter reading is 90% 3. The client has a T 100.4 F, HR 100, RR 24 and BP 102/60 4 The clients urine output is 150 mL in 4 hrs

2 (cool water gives immediate and striking relief from pain and limits local tissue edema and damage. WRONG: #1 Ice should NEVER be applied to a burn because this will worsen the tissue damage causing vasoconstriction. #3 Burn ointment should not be applied until the burning has stopped, cool water first #4 The client should be told to go to the ED not the office for burn care)

NP I CS 7) Ms Glada is teaching a group of community members about fire safety. A participant asks "What should I do if I get a hot grease burns on my my hand"? Which statement is Ms. Gladas best response? 1. Apply an ice pack directly to the hand 2. Place the hand under cool tap water 3. Put burn ointment on the hand 4. Go immed to the doctors office

3 ( This client's vital signs indicate that the life-threatening complications of sepsis and septic shock may be developing. The other clients also need rapid assessment and/or nursing interventions, but their symptoms do not indicate that they need care as urgently as the febrile and hypotensive client. Focus: Prioritization)

16. You have just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention? 1. 22-year-old admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left 2. 34-year-old who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (on a scale of 0 to 10) 3. 45-year-old with partial-thickness leg burns who has a temperature of 102.6° F (39.2° C) and a blood pressure of 98/46 mm Hg 4. 57-year-old who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L

3 ( A new graduate would be familiar with the procedure for a sterile dressing change, especially after working for 3 weeks on the unit. Clients whose care requires more complex skills such as admission assessments, preprocedure teaching, and discharge teaching should be assigned to more experienced RN staff members. Focus: Assignment)

18. You are the charge nurse on a medical-surgical unit and are working with a newly-graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? 1. 34-year-old who was just admitted to the unit with periorbital cellulitis 2. 40-year-old who needs discharge instructions after having skin grafts to the thigh 3. 67-year-old who requires a dressing change after hydrotherapy for a pressure ulcer 4. 78-year-old who needs teaching before a punch biopsy of a facial lesion

1 (The UAP can put the pulse oximeter on the clients finger and record the number. Ms Kathy must evaluate the reading to determine if wnl)

NP I CS 5) Which nursing task should Ms Kathy the RN delegate to the UAP for the client with full thickness burns over the R leg? 1. Instruct the UAP to take the clients pulse oximeter reading 2. Tell the UAP to change the dressing on the R leg 3. Ask the UAP to apply mafenide acetate, Sulfamylon, to the R leg 4. Request the UAP to complete the admission assessment

2 (Pain is the clients priority problem. The client has full thickness burn, which has no pain, but the DEEP partial thickness burns are VERY painful. WRONG: #1 This is a pertinent problem because the protective barrier has been compromised and there is impaired immune response, but not priority over pain #3 Burn wound edema, pain, and potential joint contractures can cause mobility deficit, but not before infection which follows pain. #4 AFTER 48-72 hrs F&E is no longer the priority. This client is 4 DAYS POST initial burn)

PD CS I 3) Ms Glada is developing a nursing care plan for a client who experienced full thickness burn and deep partial-thickness burns over half the body 4 days ago Which client problem should Ms. Glada make priority? 1. High risk for infection 2. Pain 3. Impaired physical mobility 4. Fluid and electrolyte balance

3 (The UAP is attempting to move a client who weighs more than 400 lbs to the bedside commode. The UAP should request assistance to ensure client safety as well as to protect the UAPs back. This is a dangerous situation and requires intervention by the nurse)

PD I 15) The nurse in the rehab unit is caring for clients along with a UAP. Which action by the UAP warrants immed intervention? 1. The UAP assists the client 1 week post op to eat a reg diet 2. The UAP calls for assistance when taking the client to the shower 3. The UAP is assisting the client who weighs 181 kg to the bedside commode 4. The UAP places the call light within reach of the client who is sitting in the chair