Hesi medsurg level 4 exam

HESI MEDSURG LEVEL 4 EXAM

, Hesi medsurg level 4 exam
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?
You Selected:

 36%

Correct response:

 36%

Explanation:

The Rule of Nines divides body surface area into percentages that, when totaled, equal
100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs
account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's
burns cover 36% of the body surface area.
Reference:

 Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management
of Patients with Burn Injury, Rule of Nines, p. 1848.
Chapter 62: Management of Patients with Burn Injury - Page 1848
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Question 2 See full question


22s

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When planning care for a client with burns on the upper torso, which nursing diagnosis
should take the highest priority?
You Selected:

 Ineffective airway clearance related to edema of the respiratory passages

Correct response:

 Ineffective airway clearance related to edema of the respiratory passages

Explanation:

,When caring for a client with upper torso burns, the nurse's primary goal is to maintain
respiratory integrity. Therefore, Ineffective airway clearance related to edema of the
respiratory passages should take the highest priority. Impaired physical mobility related
to the disease process isn't appropriate because burns aren't a disease. Disturbed
sleep pattern related to facility environment and Risk for infection related to breaks in
the skin may be appropriate, but they don't command a higher priority than Ineffective
airway clearance because they don't reflect immediately life-threatening problems.
Reference:

 Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management
of Patients with Burn Injury, Chart 62-6, p. 1857.
Chapter 62: Management of Patients with Burn Injury - Page 1857
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Question 3 See full question


1m 17s

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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?
You Selected:

 A urine output consistently above 40 ml/hour

Correct response:

 A urine output consistently above 40 ml/hour

Explanation:

In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood
pressure that provides adequate perfusion of vital structures. If the kidneys are
adequately perfused, they will produce an acceptable urine output of at least 0.5
ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine
output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation
isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body
temperature readings and ECG interpretations may demonstrate secondary benefits of
fluid resuscitation but aren't primary indicators.
Reference:

,  Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management
of Patients with Burn Injury, Medical Management, p. 1854.
Chapter 62: Management of Patients with Burn Injury - Page 1854
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Question 4 See full question


1m 45s

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The most important intervention in the nutritional support of a client with a burn injury is
to provide adequate nutrition and calories to
You Selected:

 decrease catabolism.

Correct response:

 decrease catabolism.

Explanation:

The most important intervention in the nutritional support of a client with a burn injury is
to provide adequate nutrition and calories to decrease catabolism. Nutritional support
with optimized protein intake can decrease the protein losses by approximately 50%. A
marked increase in metabolic rate is seen after a burn injury and interventions are
instituted to decrease metabolic rate and catabolism. A marked increase in glucose
demand is seen after a burn injury and interventions are instituted to decrease glucose
demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving
as the energy source is seen after a burn injury and interventions are instituted to
decrease catabolism.
Reference:

 Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management
of Patients with Burn Injury, p. 1865.
Chapter 62: Management of Patients with Burn Injury - Page 1865
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Question 5 See full question


30s