Test 4 Passpoint

The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which would most likely contribute to the achievement of this goal?

administering famotidine as ordered

The nurse is teaching a 16-year-old client how to self-catheterize following a spinal cord injury. Which statements by the nurse are correct? Select all that apply.

-Drink caffeinated drinks sparingly. -Self-catheterize according to a schedule. -Maintain a regular pattern of fluid intake over the day.

A client has burns on both hands and upper arms. Which nursing actions will be most helpful in preventing contractures? Select all that apply.

-Keep the hands elevated -Apply splints as prescribed -Collaborate with the physical therapist

The nurse is caring for a client with second- and third-degree burns. Which medications will the nurse prepare? Select all that apply.

-methadone hydrochloride I.V. -morphine sulfate I.V.

A nurse is caring for a client with a history of spinal cord injury. Which nursing actions can reduce the risk for autonomic dysreflexia? Select all that apply.

-monitor the patency of the indwelling urinary catheter -promote a high fiber diet, and the use of a stool softener

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.

36

A client is admitted with a spinal cord injury at level C3. The nurse notes a heart rate of 50 beat/minute and a blood pressure of 90/60 mmHg. What is the nurse's priority action? You Selected:

Administer rapid infusion of intravenous fluids.

A client with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which action should the nurse take?

Assess oxygen saturation using pulse oximetry.

The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which response by the nurse would provide the most accurate information?

"Lack of weight bearing causes demineralization of the long bones."

During morning care, a nurse notes that a client who's had a spinal cord injury has experienced a change in level of consciousness and isn't answering questions appropriately. The nurse checks the client's vital signs and measures the client's blood pressure at 180/110 mm Hg and heart rate at 125 beats/minute. The nurse determines that the client may be experiencing dysreflexia. What other assessments should the nurse make? Select all that apply.

-most recent bowel movement -urine output -pain level

A nurse is caring for a client experiencing difficulty swallowing following a spinal cord injury and the placement of a halo traction device. Which nursing interventions are most appropriate for this client? Select all that apply.

-place client in an upright position to eat -verify that a cough reflex is present -verify that a gag reflex is present -assist the client to select foods from a mechanical soft diet

Two months after an adolescent's thoracic spinal cord injury, he has a pounding headache. The nurse notes that the client's arms and face are flushed and he is diaphoretic. What should the nurse do next?

Check the patency of the urinary catheter.

An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?

Cover the adolescent's legs with blankets.

When planning to move a person with a possible spinal cord injury, the nurse should direct the team to move the client using which procedure?

Immobilize the head and neck to prevent further injury.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

A 30-year-old client is admitted to the progressive care unit with a C5 fracture from a motorcycle accident. What would be the nurse's priority assessment?

Pulse oximetry readings

A 5-year-old child is brought to the emergency department after injuries sustained in a motor vehicle accident. The child is diagnosed with a cervical spinal cord injury. Which assessment data would the nurse consider as most significant when assessing for signs of cervical spinal cord swelling?

changes in respiration

A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to

clean the area with normal saline solution and cover it with a protective dressing.

The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown in the accompanying image. Which finding is expected when assessing this client?

dysfunction of bowel and bladder

A nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client?

hemodilution

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to

increase the frequency of the catheterizations.

A teenage client is admitted to the burn unit with burns over 49% of the body surface area, including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused and reports minor pain. When assessing the client, which is an immediate priority for the nurse to evaluate?

patency of airway

The nurse is caring for a client with a T-5 spinal cord injury. The client is on bed rest and has an indwelling urinary catheter. The client has a pounding headache, profuse diaphoresis, and nausea. Which nursing action is the priority?

placing the client upright in a sitting position

The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas. Which position would be most appropriate for preventing contractures?

supine

A school-age child with burns on the trunk and arms has no appetite. The nurse and the parent develop a plan of care to stimulate the child's appetite. Which suggestion made by the parent would indicate the need for additional teaching?

withholding dessert and treats unless meals are eaten

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should

wrap elastic bandages distally to proximally on dependent areas

A client who has severe thermal burns and is on mechanical ventilation becomes delusional and attempts to remove the tubes. The nurse gives the client propofol, a sedative. As a result, it's most important that the client receive a supplementation of

zinc

The nurse is caring for an adolescent on a burn unit who has sustained third-degree burns over 40% of the body. A family member asks why the client is not reporting more pain. How should the nurse respond?

"The severe burns have damaged nerves that sense pain."

Throughout the first 3 weeks after a client has had a C7 spinal cord injury, the nurse should particularly assess the client for which findings? Select all that apply.

-tachycardia -rapid respirations -bladder incontinence

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?

urine output of 30 mL/h