MED/SURG 1 Exam 5 st st st
Youstarestastnursestmanagerstinstthestburnstunit.stWhichstclientstisstbeststtostassign
sttostanstRNstwhosthasstfloatedstfromstthestoncologystunit?
a.st23styearstoldstwhosthasstjuststbeenstadmittedstwithstburnsstoverst30%stofstthestb
odystafterstastwarehousestfire
b.st36styearstoldstwhostrequiresstdischargestteachingstaboutstnutritionstandstwou
ndstcarestaftersthavingstskinstgrafts
c.st45styearstoldstwithstinfectedstpartial-
thicknessstbackstandstcheststburnsstwhosthasstastdressingstchangestscheduled
d.st57styearstoldstwithstfull-
thicknessstburnsstonstbothstarmsstwhostneedsstassistancestinstpositioningsthandst
splintsst-stcorrectstanswer✔ ✔ c
Yousthavestjuststreceivedstastchange-of-
shiftstreportstforstthestburnstunit.stWhichstclientstshouldstyoustassessstfirst?
a.stClientstwithstdeepstpartial-
thicknessstburnsstonstbothstlegsstwhostreportsstseverestandstcontinuousstlegstpai
n
b.stClientstwhosthasstjuststarrivedstfromstthestemergencystdepartmentstwithstfaci
alstburnsstsustainedstinstasthousestfire
c.stClientstwhosthasstjuststbeensttransferredstfromstthestpoststanesthesiastcarestuni
tstaftersthavingstskinstgraftsstappliedsttostthestanteriorstchest
,d.stClientstadmittedst3stweeksstagostwithstfull-
thicknessstlegstandstbuttocksstburnsstwhosthasstbeenstwaitingst3sthourssttostrecei
vestdischargestteachingst-stcorrectstanswer✔ ✔ b
Duringstthestemergentstphasestofstburnstcare,stwhichstassessmentstwillstbestmost
stusefulstinstdeterminingstwhetherstthestpatientstisstreceivingstadequatestfluidstin
fusion?
a.stCheckstskinstturgor.
b.stMonitorstdailystweight.
c.stAssessstmucousstmembranes.
d.stMeasuresthourlysturinestoutput.st-stcorrectstanswer✔ ✔ d
Ast10styearstoldsthasstjuststspilledsthotstliquidstonsthisstarm,standstast4-
inchstareastonsthisstforearmstisstburned.stHisstmotherstcallsstthestemergencystdep
artment.stWhatstshouldstthestnursestadvisestthestmothersttostdo?
a.stkeepstthestchildstwarm
b.stcoverstthestburnstareastwithstanstantibioticstcreamstandstastband-aid
c.stapplystcoolstwatersttostthestburnedstarea
d.stcallst911sttosttransportstthestchildsttostthesthospitalst-stcorrectstanswer✔ ✔
c
AstclientstisstreceivingstfluidstreplacementstwithstLactatedstRinger'sstafterst40%
stofstthestbodystwasstburnedst10sthoursstago.stThestassessmentstrevealssttemperat
, urestofst90.6,stheartstratest122,stbloodstpressurest84/42,standsturinestoutputstofst25
stmLstforstthestpastst2sthours.stThestIVstratestisstcurrentlystatst375stmL/hr.stUsingst
SBARsttechniquestforstcommunication,stthestnursestcallsstthesthealthstcarestpro
viderstwithstastrecommendationstfor:
a.stfurosemide
b.stfreshstfrozenstplasma
c.stIvstratestincrease
d.stdextrosest5%st-stcorrectstanswer✔ ✔ c
Thestnursestisstcaringstforstastclientstwithstseverestburnsstwhostisstreceivingstfluids
tresuscitation.stWhichstofstthestfollowingstindicatesstthatstthestclientstisstrespon
dingsttostthestfluidstresuscitation?st
a.stpulsestratestofst112
b.stbloodstpressurestofst94/64
c.sturinestoutputstofst50stmL/hr
d.stserumstsodiumstlevelstofst136stmEq/Lst-stcorrectstanswer✔ ✔
c.sturinestoutputstofst50stmL/HR
Thestnursestisstassessingstanst80styearstoldstclientstwhosthasstscaldstburnsstonstthest
handsstandstbothstforearmsst(firststandstsecond-
degreestburnsstonst10%stofstthestbodystsurfacestarea.)stWhatstshouldstthestnursest
dostfirst?
a.stcleanstthestwoundsstwithstwarmstwater
Youstarestastnursestmanagerstinstthestburnstunit.stWhichstclientstisstbeststtostassign
sttostanstRNstwhosthasstfloatedstfromstthestoncologystunit?
a.st23styearstoldstwhosthasstjuststbeenstadmittedstwithstburnsstoverst30%stofstthestb
odystafterstastwarehousestfire
b.st36styearstoldstwhostrequiresstdischargestteachingstaboutstnutritionstandstwou
ndstcarestaftersthavingstskinstgrafts
c.st45styearstoldstwithstinfectedstpartial-
thicknessstbackstandstcheststburnsstwhosthasstastdressingstchangestscheduled
d.st57styearstoldstwithstfull-
thicknessstburnsstonstbothstarmsstwhostneedsstassistancestinstpositioningsthandst
splintsst-stcorrectstanswer✔ ✔ c
Yousthavestjuststreceivedstastchange-of-
shiftstreportstforstthestburnstunit.stWhichstclientstshouldstyoustassessstfirst?
a.stClientstwithstdeepstpartial-
thicknessstburnsstonstbothstlegsstwhostreportsstseverestandstcontinuousstlegstpai
n
b.stClientstwhosthasstjuststarrivedstfromstthestemergencystdepartmentstwithstfaci
alstburnsstsustainedstinstasthousestfire
c.stClientstwhosthasstjuststbeensttransferredstfromstthestpoststanesthesiastcarestuni
tstaftersthavingstskinstgraftsstappliedsttostthestanteriorstchest
,d.stClientstadmittedst3stweeksstagostwithstfull-
thicknessstlegstandstbuttocksstburnsstwhosthasstbeenstwaitingst3sthourssttostrecei
vestdischargestteachingst-stcorrectstanswer✔ ✔ b
Duringstthestemergentstphasestofstburnstcare,stwhichstassessmentstwillstbestmost
stusefulstinstdeterminingstwhetherstthestpatientstisstreceivingstadequatestfluidstin
fusion?
a.stCheckstskinstturgor.
b.stMonitorstdailystweight.
c.stAssessstmucousstmembranes.
d.stMeasuresthourlysturinestoutput.st-stcorrectstanswer✔ ✔ d
Ast10styearstoldsthasstjuststspilledsthotstliquidstonsthisstarm,standstast4-
inchstareastonsthisstforearmstisstburned.stHisstmotherstcallsstthestemergencystdep
artment.stWhatstshouldstthestnursestadvisestthestmothersttostdo?
a.stkeepstthestchildstwarm
b.stcoverstthestburnstareastwithstanstantibioticstcreamstandstastband-aid
c.stapplystcoolstwatersttostthestburnedstarea
d.stcallst911sttosttransportstthestchildsttostthesthospitalst-stcorrectstanswer✔ ✔
c
AstclientstisstreceivingstfluidstreplacementstwithstLactatedstRinger'sstafterst40%
stofstthestbodystwasstburnedst10sthoursstago.stThestassessmentstrevealssttemperat
, urestofst90.6,stheartstratest122,stbloodstpressurest84/42,standsturinestoutputstofst25
stmLstforstthestpastst2sthours.stThestIVstratestisstcurrentlystatst375stmL/hr.stUsingst
SBARsttechniquestforstcommunication,stthestnursestcallsstthesthealthstcarestpro
viderstwithstastrecommendationstfor:
a.stfurosemide
b.stfreshstfrozenstplasma
c.stIvstratestincrease
d.stdextrosest5%st-stcorrectstanswer✔ ✔ c
Thestnursestisstcaringstforstastclientstwithstseverestburnsstwhostisstreceivingstfluids
tresuscitation.stWhichstofstthestfollowingstindicatesstthatstthestclientstisstrespon
dingsttostthestfluidstresuscitation?st
a.stpulsestratestofst112
b.stbloodstpressurestofst94/64
c.sturinestoutputstofst50stmL/hr
d.stserumstsodiumstlevelstofst136stmEq/Lst-stcorrectstanswer✔ ✔
c.sturinestoutputstofst50stmL/HR
Thestnursestisstassessingstanst80styearstoldstclientstwhosthasstscaldstburnsstonstthest
handsstandstbothstforearmsst(firststandstsecond-
degreestburnsstonst10%stofstthestbodystsurfacestarea.)stWhatstshouldstthestnursest
dostfirst?
a.stcleanstthestwoundsstwithstwarmstwater
