Exam 9 Study Questions

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the ores nice of a loop of bowel protruding through the incision. Which interventions should the nurse take? (SATA) 1. Contact surgeon 2. Instruct client to remain quiet 3. Prepare client for wound closure 4. Document the findings and actions take 5. Place a sterile saline dressing and ice packs over the wound 6. Place the client in a supine position without a pillow under the head

1. Contact surgeon 2. Instruct client to remain quiet 3. Prepare client for wound closure 4. Document the findings and actions take

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreasing edema formation 4. Formation of granulation tissue

1. Return of distal pulses

A client is brought to the ED with partial-thicken as burns to his face, neck, arms and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (SATA) 1. Restrict fluids 2. Assess for airway patency 3. Administer oxygen as prescribed 4. Place a cooling blanket on the client 5. Elevate extremities if no fractures are present 6. Prepare to give oral pain medication as prescribed

2. Assess for airway patency 3. Administer oxygen as prescribed 5. Elevate extremities if no fractures are present

The nurses assessed a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serious drainage 3. Purulent drainage 4. Warm, tender skin

2. Serous drainage

The nurse is administering fluids IV as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy if fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

2. Urine output

An adult client was burned in an explosion. The burn initially affected the client's entire face and the upper half of the anterior torso and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, causing subsequent burn injuries to the posterior surface of the head and upper half of the posterior torso. Using the rule of mines, what would be the extent of the burn injury? 1. 18% 2. 24% 3. 36% 4. 48%

3. 36%

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What should the nurse anticipate to be prescribed for the client? 1. Out of bed activities 2. Bathroom privileges 3. Immobilization of affected leg 4. Placing the affected leg in a dependent position

3. Immobilization of affected leg

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals blood pressure of 90/50, a pulse of 110, and a urine output of 20ml over the past hour. The nurse reports the findings to the health care provider and anticipates which prescription? 1. Transfusing 1 unit of packed red blood cells 2. Administering a diuretic to increase urine output 3. Increasing the amount of IV lactated ringers solution administered per hour 4. Changing the IV lactated ringers solution to one that contains 5% dextrose in water

3. Increasing the amount of IV lactated ringers solution administered per hour

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervened if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1. Using sterile sheets and linens 2. Performing strict hand-washing 3. Wearing gloves and a gown only when giving direct care to the client 4. Wearing protective garb, including a mask, gloves, cap, shoe covers, gown and plastic apron

3. Wearing gloves and a gown only when giving direct care to the client

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula 6L 3. Oxygen via nasal cannula at 15L 4. 100% oxygen via a tight-fitting nonrebreather face mask

4. 100% oxygen via a tight-fitting nonrebreather face mask

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1. A pink, edematous hand 2. A fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color to the skin, which is insensitive to touch

4. A white color to the skin, which is insensitive to touch

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1. Decreased heart rate 2. Increased urinary output 3. Increased blood pressure 4. Elevated hematocrit levels

4. Elevated hematocrit levels