Unit 5 exam
A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? A. 2 to 5 days after surgery B. Within 12 hours after surgery C. Within 24 hours after surgery D. As soon as sanguineous drainage is noted
Answer: A. 2 to 5 days after surgery
A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames? A. 2 to 4 weeks B. 1 week C. 6 weeks D. 8 weeks
Answer: A. 2-4 weeks
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A. A urine output consistently above 40 ml/hour B. A weight gain of 4 lb (2 kg) in 24 hours C. Body temperature readings all within normal limits D. An electrocardiogram (ECG) showing no arrhythmias
Answer: A. A urine output consistently above 40 ml/hour
The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action? A. Call security personnel to assist B. Administer antipsychotic medication C. Apply physical restraints D. Move out of the client's view
Answer: A. Call security personnel to assist
A patient was involved in an avalanche that killed many people on a ski trip, including the patient's brother. The nurse is educating the patient about recognition of stress reactions and ways to manage stress. What type of process is the nurse introducing to the patient? A. Defusing B. Debriefing C. Preparedness D. Demobilization
Answer: A. Defusing
A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following? A. Ear lobe and then to the xiphoid process B. Chin and then to the xiphoid process C. Ear lobe and then to the umbilicus D. Chin and then to the umbilicus
Answer: A. Ear lobe and then to the xiphoid process
The nurse is caring for a client in the intensive care unit and while reviewing the client's history, the nurse notes the client had a King laryngeal tube inserted to begin ventilation. The nurse recognizes this intervention was required for which reason? A. Emergency response personnel performed this intervention outside the hospital. B. The client's airway is oversized requiring a specialized endotracheal tube. C. Laryngeal edema prevented placement of an endotracheal tube. D. The client was hemorrhaging into the neck.
Answer: A. Emergency response personnel performed this intervention outside the hospital.
A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next? A. Encourage the client to cough forcefully. B. Insert a nasopharyngeal airway. C. Prepare the client for a bronchoscopy. D. Insert an oropharyngeal airway.
Answer: A. Encourage the client to cough forcefully.
A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? A. Ensure a patent airway and that the patient is receiving 100% oxygen. B. Send the patient for a chest x-ray. C. Send the patient to the hyperbaric chamber. D. Draw labs for a chemistry panel.
Answer: A. Ensure a patent airway and that the patient is receiving 100% oxygen
A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? A. Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. B. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. C. Remove his burned pants so that the air can help cool the wound. D. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area.
Answer: A. Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.
A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? A. Increasing heart rate B. Pale, warm, dry skin C. Heart rate of 70 beats/minute D. Elevated blood pressure
Answer: A. Increasing heart rate
The nurse is caring for a client with known myocardial ischemia. The client will be getting up to ambulate for the first time in three days after being on bedrest since admission to the intensive care unit. Which medication should the nurse administer before the client ambulates? A. Nitroglycerin B. Vasopressin C. Norepinephrine D. Dobutamine
Answer: A. Nitroglycerin
Following a burn injury, the nurse determines which area is the priority for nursing assessment? A. Pulmonary system B. Cardiovascular system C. Pain D. Nutrition
Answer: A. Pulmonary system
A nurse is providing disaster care in an event that is known to involve gamma radiation. When admitting victims of the disaster, what should the nurse do to best reduce victims' risks of injury? A. Remove victims' clothing and have them wash themselves thoroughly. B. Carefully apply personal protective equipment over victims' clothing. C. Apply chlorhexidine to all skin surfaces that may have been contaminated. D. House victims in a well-ventilated area.
Answer: A. Remove victims' clothing and have them wash themselves thoroughly.
Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. A. Singed nasal hair B. Hoarseness C. Facial burns D. Yellow sputum E. Bradypnea
Answer: A. Singed nasal hair B. Hoarseness C. Facial burns
A nursing instructor is describing the role of a nurse during a disaster. Which of the following would best reflect the nurse's role? A. Variable depending on the needs of the situation B. Client care within the area of expertise C. Provision of comprehensive client-specific care D. Directly specified by the physician in charge
Answer: A. Variable depending on the needs of the situation
Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client? A. allograft B. xenograft C. autograft D. slit graft
Answer: A. allograft
A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? A. deep tissue cooling B. continuing inflammatory process C. protein cell coagulation D. All options are correct.
Answer: A. deep tissue cooling
Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the A. spleen. B. liver. C. gallbladder. D. large intestine.
Answer: A. spleen
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? A. 18% B. 27% C. 36% D. 45%
Answer: B. 27%
Permanent brain injury or death will occur within which time frame secondary to hypoxia? A. 1 to 2 minutes B. 3 to 5 minutes C. 6 to 8 minutes D. 9 to 10 minutes
Answer: B. 3 to 5 minutes
The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? Select all that apply. A. Wear the garment at least 12 hours each day. B. Contact the primary provider if the garment does not seem to fit properly. C. Machine wash the pressure garment daily with a mild detergent. D. Roll the garment and wring tightly to ensure garment is as dry as possible after washing. E. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
Answer: B. Contact the primary provider if the garment does not seem to fit properly. E. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
After inserting an oropharyngeal airway, which of the following indicates that the airway is properly positioned? A. Distal end is in the pharynx. B. Flange is at the client's lips. C. Air is moving through the airway. D. Tongue lies on top of the airway.
Answer: B. Flange is at the client's lips
A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? A. Hemoconcentration B. Hemodilution C. Metabolic acidosis D. Lack of erythropoietin factor
Answer: B. Hemodilution
What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply. A. Hemodilution B. Increased urinary output C. Metabolic alkalosis D. Sodium deficit E. Hypoglycemia
Answer: B. Increased urinary output D. Sodium deficit E. Hypoglycemia
The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? A. The client will require intravenous access for three days B. The client requires total parenteral nutrition C. The client requires infusion of intravenous antibiotics D. The client requires infusion of a dextrose 5% water (D5W)
Answer: B. The client requires total parenteral nutrition
A client who has been exposed to radiation develops acute radiation syndrome. It has been about 2 weeks since he initially showed signs and symptoms and the client is undergoing laboratory testing. Which of the following would the nurse expect to find? A. Altered electrolyte levels B. Thrombocytopenia C. Elevated neutrophil count D. Erythrocytosis
Answer: B. Thrombocytopenia
Which is the primary reason for placing a client in a horizontal position while smothering flames are present? A. To prevent collapse and further injuries B. To keep fire and smoke from airway C. To extinguish flames more quickly D. To promote blood flow to the brain and vital organs
Answer: B. To keep fire and smoke from airway
A finger sweep is only to be used in which client population? A. Conscious adult B. Unconscious adult C. Child D. Adolescent
Answer: B. Unconscious adult
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B. Urine output of 20 ml/hour C. White pulmonary secretions D. Rectal temperature of 100.4° F (38° C)
Answer: B. Urine output of 20 ml/hour
A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include: A. monitoring the client for the development of respiratory acidosis. B. premedicating the client with an analgesic prior to application. C. monitoring the client's Na+ and K+ serum levels and replace as prescribed. D. protecting the bed linens and client's clothing from contact to prevent staining.
Answer: B. premedicating the client with an analgesic prior to application.
Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame? A. 7 to 10 days B. 3 days C. 5 days D. 2 days
Answer: C. 5 days
The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting? A. Counselling B. Defusing C. Debriefing D. Follow up
Answer: C. Debriefing
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? A. Having the conscious client lie down B. Placing the thumb side of one hand at the xiphoid process C. Positioning the hands in the midline slightly above the umbilicus D. Using a sequence of four thrusts, each progressing in intensity
Answer: C. Positioning the hands in the midline slightly above the umbilicus
A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? A. 18% B. 27% C. 30% D. 36%
Answer: D. 36%
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? A. 9% B. 18% C. 27% D. 36%
Answer: D. 36%
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? A. Tissue hypoxia B. Infection C. Renal failure D. Hypovolemia
Answer: D. Hypovolemia
A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested? A. Face only B. Face, neck, and chest C. Face and neck D. Neck and chest
Answer: D. Neck and chest
A nurse is establishing a patient's airway. Which action would the nurse perform first? A. Giving abdominal thrusts B. Using the jaw-thrust maneuver C. Inserting an artificial airway D. Repositioning the patient's head
Answer: D. Repositioning the patient's head
A triage nurse is talking to a client when the client begins choking on his lunch. The client is coughing forcefully. What should the nurse do? A. Stand him up and perform the abdominal thrust maneuver from behind. B. Lay him down, straddle him, and perform the abdominal thrust maneuver. C. Leave him to get assistance. D. Stay with him and encourage him, but not intervene at this time.
Answer: D. Stay with him and encourage him, but not intervene at this time.
A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? A. Collecting semen B. Performing the pelvic examination C. Obtaining consent for examination D. Supporting the client's emotional status
Answer: D. Supporting the client's emotional status
A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose? A. Delayed B. Emergent C. Immediate D. Urgent
Answer: D. Urgent
The nurse is assessing a victim who is reported to have been exposed to sulfur mustard. The nurse's assessment should include evaluation for A. pulmonary edema. B. diarrhea. C. cardiac arrest and death. D. partial-thickness burns.
Answer: D. partial-thickness burns
A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. A. "This medication is an antibacterial." B. "This medication will be applied directly to the wound." C. "This medication will stain my skin permanently." D. "This medication will help my burn heal."
Answer: A. "This medication is an antibacterial." B. "This medication will be applied directly to the wound." D. "This medication will help my burn heal."
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? A. BUN: 28 mg/dL B. K+: 5.0 mEq/L C. Na+: 145 mEq/L D. Ca: 9 mg/dL
A. BUN: 28 mg/dL
A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make? A. "It reduces the risk of complications from an infection." B. "It reduces the amount of scarring that will occur on the skin." C. "It reduces the amount of wound care that you will need as the skin heals." D. "it encourages your body's natural processes to liquefy any damaged tissue."
Answer: A. "It reduces the risk of complications from an infection."