EXAM 4 practice questions: UPDATED ACTUAL Questions And Correct Answers
C
Terms in this set (178)
A nurse is caring for a client who has third-degree burns C
on the right hand from a kitchen fire. The client is
scheduled to go for a skin graft procedure tomorrow.
Physical therapy is coming within the hour. The client is
sitting in the room with the lights out and is staring out
the window. What action does the nurse take first?
A) Provide client education about the upcoming skin
graft and sign the informed consent for surgery.
B) Assess the status of the dressing on the clients hand.
C) Say to the client, "People with burns experience a lot
of emotions and frustrations. Tell me what you are feeling
right now."
D) Help the client put on shoes and get ready for the
physical therapy visit.
A male client sustains burns and is brought to the 3635mL
emergency department for care. The client is estimated
to weigh 160lbs. The client is estimated to have 25% of his
body burned. Using the parkland formula, how much
lactated ringers should be administered in the first eight
hours of his care?
,The nurse is caring for a client who was in a house fire B
and has full-thickness burns on the back of both arms
and the back of the head. The client's face has superficial
burns on the face. The client weighs 60kg. Using the rule
of nines and the Parkland formula with 4mL lactated
ringers IV, how much IV fluid does the client need in the
first 24hrs following the burns?
A) 1620mL
B) 3240mL
C) 4320mL
D) 8640mL
The nurse is administering IV fluids to a client who C
sustained full-thickness burns on the front of both legs
and the feet. The client weighs 55kg. What finding by the
nurse indicates the effectiveness of fluid resuscitation?
A) mean arterial pressure (MAP) 40mmHg
B) systolic blood pressure of 82mmHg
C) urine output 30mL in the last hour
D) heart rate 130 beats per min
A nurse is inserting an intermittent catheter in a female 6
client who sustained full and partial thickness burns to the 5
chest and abdomen. In what order would the nurse 3
perform these actions? 1
1. Open packet of lubricant and lubricate catheter 2
2. Clean labia and urinary meatus 4
3. Place sterile drape on bed between clients thighs
4. Insert catheter into urethral meatus
5. Apply sterile gloves
6. Perform hand hygiene
A client comes to the emergency department after 2, 3,5,6
sustaining burns from a house fire. The client has 27%
total body surface area that is affected by the burns.
What are the priority nursing actions? SATA
1. Immerse the client in cool water
2. remove as much of the clients clothing as possible
3. Administer opioid analgesics as prescribed
4. Flush the clients eyes with tap water
5. Initiate two intravenous lines
6. Insert an indwelling urinary catheter
Which prevention strategy would the nurse include when c. Encourage regular home fire exit drills.
teaching about home fire safety?
a. Set hot water temperature at 140°F.
b. Use only hardwired smoke detectors.
c. Encourage regular home fire exit drills.
d. Do not allow older adults to cook unattended.
, The injury that is least likely to result in a full-thickness a. sunburn
burn is
a. sunburn. Rationale: Full-thickness burns may be caused by contact with flames, scalding
b. scald injury. liquids, chemicals, tar, or electrical current.
c. chemical burn.
d. electrical injury
When assessing a patient with a partial-thickness burn, A, D, E
the nurse would expect to find (select all that apply)
a. blisters.
b. exposed fascia.
c. exposed muscles.
d. intact nerve endings.
e. red, shiny, wet appearance
A patient is admitted to the burn center with burns to his D
head, neck, and anterior and posterior chest after an
explosion in his garage. On assessment, the nurse
auscultates wheezes throughout the lung fields. On
reassessment, the wheezes are gone, and the breath
sounds are greatly decreased. Which action is the most
appropriate for the nurse to take next?
a. Encourage the patient to cough and auscultate the
lungs again.
b. Obtain vital signs, oxygen saturation, and a STAT
arterial blood gas.
c. Document the findings and continue to monitor the
patient's breathing.
d. Anticipate the need for endotracheal intubation and
notify the provider
Fluid and electrolyte shifts that occur during the early c. movement of sodium and water into the interstitial space.
emergent phase of a burn injury include
a. adherence of albumin to vascular walls.
b. movement of potassium into the vascular space.
c. movement of sodium and water into the interstitial
space.
d. hemolysis of red blood cells from large volumes of
rapidly administered fluid
To maintain a positive nitrogen balance in a major burn, a. eat a high-protein, high-carbohydrate diet.
the patient must
a. eat a high-protein, high-carbohydrate diet.
b. increase normal caloric intake by about four times.
c. eat at least 1500 calories/day in small, frequent meals.
d. eat a gluten-free diet for the chemical effect on
nitrogen balance
C
Terms in this set (178)
A nurse is caring for a client who has third-degree burns C
on the right hand from a kitchen fire. The client is
scheduled to go for a skin graft procedure tomorrow.
Physical therapy is coming within the hour. The client is
sitting in the room with the lights out and is staring out
the window. What action does the nurse take first?
A) Provide client education about the upcoming skin
graft and sign the informed consent for surgery.
B) Assess the status of the dressing on the clients hand.
C) Say to the client, "People with burns experience a lot
of emotions and frustrations. Tell me what you are feeling
right now."
D) Help the client put on shoes and get ready for the
physical therapy visit.
A male client sustains burns and is brought to the 3635mL
emergency department for care. The client is estimated
to weigh 160lbs. The client is estimated to have 25% of his
body burned. Using the parkland formula, how much
lactated ringers should be administered in the first eight
hours of his care?
,The nurse is caring for a client who was in a house fire B
and has full-thickness burns on the back of both arms
and the back of the head. The client's face has superficial
burns on the face. The client weighs 60kg. Using the rule
of nines and the Parkland formula with 4mL lactated
ringers IV, how much IV fluid does the client need in the
first 24hrs following the burns?
A) 1620mL
B) 3240mL
C) 4320mL
D) 8640mL
The nurse is administering IV fluids to a client who C
sustained full-thickness burns on the front of both legs
and the feet. The client weighs 55kg. What finding by the
nurse indicates the effectiveness of fluid resuscitation?
A) mean arterial pressure (MAP) 40mmHg
B) systolic blood pressure of 82mmHg
C) urine output 30mL in the last hour
D) heart rate 130 beats per min
A nurse is inserting an intermittent catheter in a female 6
client who sustained full and partial thickness burns to the 5
chest and abdomen. In what order would the nurse 3
perform these actions? 1
1. Open packet of lubricant and lubricate catheter 2
2. Clean labia and urinary meatus 4
3. Place sterile drape on bed between clients thighs
4. Insert catheter into urethral meatus
5. Apply sterile gloves
6. Perform hand hygiene
A client comes to the emergency department after 2, 3,5,6
sustaining burns from a house fire. The client has 27%
total body surface area that is affected by the burns.
What are the priority nursing actions? SATA
1. Immerse the client in cool water
2. remove as much of the clients clothing as possible
3. Administer opioid analgesics as prescribed
4. Flush the clients eyes with tap water
5. Initiate two intravenous lines
6. Insert an indwelling urinary catheter
Which prevention strategy would the nurse include when c. Encourage regular home fire exit drills.
teaching about home fire safety?
a. Set hot water temperature at 140°F.
b. Use only hardwired smoke detectors.
c. Encourage regular home fire exit drills.
d. Do not allow older adults to cook unattended.
, The injury that is least likely to result in a full-thickness a. sunburn
burn is
a. sunburn. Rationale: Full-thickness burns may be caused by contact with flames, scalding
b. scald injury. liquids, chemicals, tar, or electrical current.
c. chemical burn.
d. electrical injury
When assessing a patient with a partial-thickness burn, A, D, E
the nurse would expect to find (select all that apply)
a. blisters.
b. exposed fascia.
c. exposed muscles.
d. intact nerve endings.
e. red, shiny, wet appearance
A patient is admitted to the burn center with burns to his D
head, neck, and anterior and posterior chest after an
explosion in his garage. On assessment, the nurse
auscultates wheezes throughout the lung fields. On
reassessment, the wheezes are gone, and the breath
sounds are greatly decreased. Which action is the most
appropriate for the nurse to take next?
a. Encourage the patient to cough and auscultate the
lungs again.
b. Obtain vital signs, oxygen saturation, and a STAT
arterial blood gas.
c. Document the findings and continue to monitor the
patient's breathing.
d. Anticipate the need for endotracheal intubation and
notify the provider
Fluid and electrolyte shifts that occur during the early c. movement of sodium and water into the interstitial space.
emergent phase of a burn injury include
a. adherence of albumin to vascular walls.
b. movement of potassium into the vascular space.
c. movement of sodium and water into the interstitial
space.
d. hemolysis of red blood cells from large volumes of
rapidly administered fluid
To maintain a positive nitrogen balance in a major burn, a. eat a high-protein, high-carbohydrate diet.
the patient must
a. eat a high-protein, high-carbohydrate diet.
b. increase normal caloric intake by about four times.
c. eat at least 1500 calories/day in small, frequent meals.
d. eat a gluten-free diet for the chemical effect on
nitrogen balance
