Health Restoration Final Exam

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 TBSA) What should the nurse do first? A. Clean the wounds with warm water B. Apply antibiotic cream C. Refer the client to a burn center D. Cover the burns with a sterile dressing

D. Cover the burns with a sterile dressing

The nurse is conducting a focused assessment of the gastrointestinal system of a client with a burn injury . The nurse should assess the client for: A. Paralytic ileus B. Gastric distention. C. Hiatal hernia. D. Curling's ulcer

D. Curling's ulcer

During the emergent (resuscitative)phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation?A) Serum creatinine level of 2.5 mg/ dL (221 μmol/ L). B) Little fluctuation in daily weight. C) Hourly urine output of 60 mL. D) Serum albumin level of 3.8 (38 g/ L).

A) Serum creatinine level of 2.5 mg/ dL (221 μmol/ L).

A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? A. Carbonaceous sputum B. Hair singeing on the head and nose C. Lhermitte's Sign D. Bright red lips E. Hoarse voice F. Tachycardia

A. Carbonaceous sputum B. Hair singeing on the head and nose D. Bright red lips E. Hoarse voice F. Tachycardia

A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned?* A. 46% B. 37% C. 36% D. 28%

B. 37%

A client is admitted to the hospital after sustaining burns to the chest, abdomen , right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," estimate what percentage of the client's body surface has been burned. A) 18%. B) 27%. C) 45%. D) 64%.

C) 45%.

A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage that is burned?* A. 40.5% B. 49.5% C. 58.5% D. 67.5%

C. 58.5%

The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for a laryngeal communication. What form of a laryngeal communication will likely be chosen? A. Esophageal speech B. Electric larynx C. Tracheoesophageal puncture D. American sign language (ASL)

C. Tracheoesophageal puncture

A client with burns to 40% of the body arrives at the emergency room. Which prescriptions by the primary healthcare provider should the nurse anticipate? Select all that apply. a) Administration of lactated Ringer's (L) solution intravenously b) Monitoring the client's body temperature c) Administration of 100% humidified oxygen d) Education about the importance of good nutrition e) Insertion of a nasogastric tube

a) Administration of lactated Ringer's (L) solution intravenously b) Monitoring the client's body temperature c) Administration of 100% humidified oxygen e) Insertion of a nasogastric tube

Prone positioning is being used for a patient with acute respiratory distress syndrome (ARDS). Which information obtained by the nurse indicates that the positioning is effective? a. The patient's Pa0z is 89 mm Hg, and the Sa02 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patient's back is intact and without redness.

a. The patient's Pa0z is 89 mm Hg, and the Sa02 is 91%

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding is important to report to the health care provider? a. The patient states that the pelvis feels unstable b. Abdomen is distended and bowel sounds are absent. c. There are ecchymoses across the abdomen and hips. d. The patient complains of pelvic pain with palpation

b. Abdomen is distended and bowel sounds are absent

A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound? a. Silver sulfadiazine cream b. Mafenide acetate cream c. Biobrane dressing d. Silver nitrate 0.5% aqueous solution

b. Mafenide acetate cream

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation

b. Tape a nonporous dressing on three sides over the chest wound.

A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates that the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating

b. The patient advances the left leg and both crutches together and then advances the right leg.

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position b. avoid handling the cast using fingertips c. place gauze around the cast edge to pad any roughness d. cover the cast with a small blanket to absorb the dampness

b. avoid handling the cast using fingertips

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

b.Ask the patient about abdominal discomfort.

A client has undergone coronary artery bypass graft surgery, which was complicated by prolonged Cardiopulmonary bypass and hypotension. After 3 hours, the client's condition stabilizes to a normal BP.However, the urine output remains insufficient. The nurse expects the physician to add which drug, at Which flow rate, to the client's regimen? A. Dobutamine 10 mcg/kg/minute b. Epinephrine 4 mcg/ kg/ minute c. Dopamine 3 mcg/kg/minute d. Norepinephrine 8 mcg/minute

c. Dopamine 3 mcg/kg/minute

A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective? a. No new heart murmurs b. Decreased troponin level c. Warm, pink, and dry skin d. Blood pressure 92/40 mm Hg

c. Warm, pink, and dry skin

Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm plaster cast? a."I can get the cast wet as long as I dry it right away with a hair dryer." b."I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours."

c."I will apply an ice pack to the cast over the fracture site off and on for 24 hours."

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Palpate for abdominal pain. c. Ask the patient about nausea. d. Check stools for occult blood.

d. Check stools for occult blood.

Twelve hours after the patient was involved in a traumatic accident, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action? a. Increase the IV infusion rate b. Reposition the patient onto the right side c. Administer a laxative d. Document the findings

d. Document the findings

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].)a. Obtain blood and urine cultures.b. Give vancomycin (Vancocin) 1 g IV.c. Start norepinephrine (Levophed) 0.5 mcg/min.d. Infuse normal saline 2000 mL over 30 minutes.e. Titrate oxygen administration to keep O2 saturation >95%.

e. Titrate oxygen administration to keep O2 saturation >95%.