Ch. 62 Brunner's Burn injury
when using the palmar methood to estimate the extnent of the burn , the nurse determines the palm is equal to which percentage of total body surface? a. 4 b. 1 c. 3 d. 2
b. 1
the nurse recognizes that the first dressing change at the site of an autograft is performed a. within 12 hours b. as soon as foul odor or purulent drainage is noted, or 2-5 days after surgery c. within 24 hour after surgery d. as soon as sanguineous drainage is noted
b. as soon as foul odor or purulent drainage is noted, or 2-5 days after surgery
which complication is common for victims of electrical burns? a. hypovolemic shock b. cardiac dysrhythmia c. infection d. inhalation injury
b. cardiac dysrhythmia
which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? a. chemical b. mechanical c. surgical d. natural
b. mechanical
which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? a. cover client with a wet cloth b. roll client in a blanket c. avoid immediate IV fluid therapy d. place client with head positioned slightly below rest of body
b. roll client in a blanket
the nurse cares for a client with extensive burn injuries. which of the following parameter(s) would the nurse evaluate to determine of the client is receiving adequate fluid resuscitation? select all that apply a. BP b. HR c. urine output d. O2 sats
a. BP b. HR c. urine output
which assessment technique should the nurse use to assess the percentage of burn injury? a. compare clients palm with size of burn b. check VS c. observe color of wounds d. observe client's LOC
a. compare clients palm with size of burn
what is an early sign of sepsis in the burn injured client? select all that apply a. widened pulse pressure b. clammy skin c. hypothermia d. increased pulse rate
a. widened pulse pressure d. increased pulse rate
acticoat antimicrobial barrier dressings usd in the treatment of burn wounds can be left in place for which time frame? a. 7-10 days b. 3 days c. 5 days d. 2 days
c. 5 days
a client is brought to the ER following a burn form a high voltage power line. the triage nurse determines which intervention should be done first? a. take VS b. insert foley catheter c. apply cervical collar d. obtain a 12 lead EKG
c. apply cervical collar
when the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? a. full thickness b. superficial c. deep partial thickness d. superficial partial thickness
c. deep partial thickness
which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? a. full thickness b. fourth degree c. deep partial thickness d. superficial partial thickness
c. deep partial thickness
which zone of burn injury sustains the most damage? a. protective b. outer c. inner d. middle
c. inner
the nurse determines which statement reflects research regarding the utilization of non pharmacological measures in the measurement of burn pain? a. pet therapy has proven effective in the management of burn pain b. music therapy diverts the client's attention toward painful stimulus c. music therapy may provide reality orientation. distraction, and sensory stimulation d. humor therapy has not proven effective in the management of burn pain
c. music therapy may provide reality orientation. distraction, and sensory stimulation
following a burn injury, the nurse determines which area is the priority for nursing assessment? a. nutrition b. pain c. pulmonary system d. cardiovascular system
c. pulmonary system
the most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to a. increase glucose demands b. increase skeletal muscle breakdown c. increase metabolic rate d. decrease catabolism
d. decrease catabolism
what is the key sign of onset of acute of respiratory distress syndrome? a. stridor b. tachypnea c. chest pain d. hypoxemia
d. hypoxemia