HESI Week 12

A client in the second (acute) phase of burn recovery may exhibit an increase in which value? a. serum sodium b. urinary output c. hematocrit level d. serum potassium

b. Urinary output as fluid returns to the vascular system, increased renal flow and diuresis occur

Which type of burn injury should be followed up by scheduling the client for an electrocardiogram (ECG)? a. Flame burn b. Chemical burn c. Electrical burn d. Radiation burn

c. Electrical burn

Which gastrointestinal (GI) change may be found in the client with burn injuries? A. Abdominal distention B. Increased peristalsis C.Activation of GI motility D. Increased blood flow to the GI area

A. Abdominal distention RATIONAL:The client with burn injuries may have abdominal distention due to loss of peristalsis. Gastrointestinal motility may be inhibited with burn injuries. Blood flow may be reduced and mucosal damage might have occurred

Which risk would the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn? A. The risk of septicemia and its potential complications from treatment B. The risk of psychosocial adjustments and resuming previous roles C. The risk of oral mucous membrane injury and its associated risks D. The risk of insufficient community resources and emotional support

a. The risk of septicemia and its potential complications from treatment Skin is the first line of defense against infection. When much of it is destroyed, the client is vulnerable to infection. Complications, such as infection and contractures, still may occur during the acute phase and as the client is healing. Psychosocial adjustments, previous roles, and insufficient community resources are priorities in the rehabilitative phase. Risk of oral mucous membrane injury is in the emergent (resuscitation) stage. Emotional support is provided in all three phases

The healthcare team is caring for clients who sustained injuries in an accidental fire. Which client should be provided with immediate care based on priority? a. client with burns to the head b. client with burns in the chest area c. client with burns in the lower extremities d. client with burns in the upper extremities

a. client with burns to the head

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. Performing an immediate appraisal, using the Rule of Nines, what is the percent of body surface area burned? a. 18% b. 22.5% c. 27% d. 36.5%

b. 22.5% entire right lower extremity - 18% (9% on each side) plus anterior portion of right extremity- 4.5%

A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. The nurse is monitoring fluid balance during the first 2 to 3 days after the burn. Which area is most important for the nurse to assess for fluid balance in this client? a. Weight every day b. Urinary output every hour c. Blood pressure every 15 minutes d. Extent of peripheral edema every 4 hours

b. Urinary output urinary output reflects circulating blood volume; it is the most reliable, immediately available information that is useful for assessing fluid needs in a burn client. Daily weight reflects fluid retention or loss; however, other factors besides fluid affect weight in a burn client. Blood pressure results may indicate hypervolemia or hypovolemia; however, it is not as accurate an indicator of insufficient fluid replacement as is urinary output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.

A severely burned client has been hospitalized for three days. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. What does the nurse conclude the client is most likely developing? a. kidney failure b. cerebral hypoxia c. metabolic acidosis d. hypovolemic shock

b. cerebral hypoxia

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? a. decreased rate of glomerular filtration b. excessive blood loss through burned tissues c. plasma proteins moving out of the intravascular compartment d. sodium retention occurring as a result of the aldosteorne mechanism

c. Plasma proteins moving out of the intravascular compartment

Which information will the nurse share with a client who sustained a burn and asks, "what is the difference between my full-thickness and deep partial-thickness burns?" a. Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns affect only the epidermis b. Full-thickness burns involve superficial layers of the epidermis; deep partial-thickness burns extend through the epidermis c. Full-thickness burns extend through the epidermis and only part of the dermis; deep partial-thickness burns extend into SQ tissue d. Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis.

d. Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis.