ANSWERES ATI RN 231 231 QUIZ 4 CLONED ASSESSM ENT 1 QUESTIONS AND ANSWERS WITH RATIONALES

ANSWERES ATI RN 231 231 QUIZ 4 CLONED ASSESSM ENT 1 QUESTIONS AND ANSWERS WITH RATIONALES 1. A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should be aware that initially the client is at greatest risk for A. airway obstruction. Rationale: Burns of the head, neck, and chest may involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care. B. infection. Rationale: Although prevention of infection is an important aspect of burn care throughout hospitalization and treatment, there is a greater initial priority for this client. C. fluid imbalance. Rationale: Although adequate fluid replacement is an important aspect of burn care throughout the acute phase of burn treatment, there is a greater initial priority for this client. D. paralytic ileus. Rationale: Although paralytic ileus may occur during the acute phase aspect of burn care and may require nasogastric suctioning, there is a greater initial priority for this client. 2. A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is pending an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? A. "Large incisions will be made in the eschar to improve circulation." Rationale: An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation. B. "I can call the doctor back here if you want me to." Rationale: This is a nontherapeutic response that defers the client's concern and puts it on hold. C. "A piece of skin will be removed and grafted over the burned area." Rationale: A surgical procedure in which a piece of skin from one area of the client's body is transplanted to another area is called a skin graft. D. "Dead tissue will be surgically removed." Rationale: Debridement is the surgical removal of dead tissue. Detailed Answer Key RN 231 Quiz 4_Cloned_Assessment 1 Created on:04/06/2018 Page 2 3. A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is the priority nursing action when the client is brought into the emergency room? A. Cover the burned area with sterile gauze. Rationale: Infection is one of the leading causes of death with burn injuries. Because the integrity of the skin is breeched, it is vital to cover all burned areas with sterile gauze; however, this is not the priority concern at this time. B. Inspect mouth for signs of inhalation injuries. Rationale: Since the client sustained burns to the chest, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, this is the priority concern at this time. C. Administer intravenous pain medication. Rationale: Because of the large percentage of burned area, this client will experience high levels of pain, since partial-thickness burns expose fragile nerve endings. Large doses of intravenous morphine or other narcotic analgesics will likely be needed for adequate pain control. Despite the fact that pain is an important issue, it is not the priority concern at this time. D. Draw blood for a complete blood cell (CBC) count. Rationale: Burn injuries, such as this one, that exceed 20% of body surface area are considered major burns, which affect the client’s metabolism, hemodynamic balance, and immune system. In the early stage of burns, increased capillary permeability allows sodium to enter cells while potassium leaks out, resulting in hyponatremia and hyperkalemia. An altered osmotic gradient and loss of intravascular fluid causes elevated hematocrit levels. Initial lab studies are important to create a baseline because of these systemic effects of burns. Those labs would include a CBC, electrolytes, BUN, creatinine, and blood glucose. While it is important to establish baseline data, it is not the priority concern at this time. 4. A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client’s total body surface area (TBSA)? A. 9 percent Rationale: Each arm represents 9% of the client’s TBSA. B. 18 percent Rationale: Each leg represents 18% of the client’s TBSA. C. 36 percent Rationale: Both legs represent 36% of the client’s TBSA. D. 54 percent Rationale: Detailed Answer Key RN 231 Quiz 4_Cloned_Assessment 1 Created on:04/06/2018 Page 3 Each arm represents 9% of the client’s TBSA and each leg represents 18% of the client’s TBSA totalling 54%. 5. A nurse is caring for a client who has full-thickness burns all over 75% of his body. Which of the following methods is appropriate to accurately monitor the cardiovascular system? A. Auscultate cuff blood pressure. Rationale: Clients who have a large percentage of burned body surface area often do not have an area for the nurse to safely apply the cuff. Additionally, cuff blood pressures are affected by peripheral vascular changes. B. Palpate pulse pressure. Rationale: Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. Palpation of pulse pressure does not provide data to detect subtle changes in the cardiovascular system. C. Obtain a central venous pressure. Rationale: Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. The central venous pressure provides important data but does not accurately detect changes in left heart pressure. D. Monitor the pulmonary artery pressure. Rationale: Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. The pulmonary artery pressure provides an accurate assessment of the cardiovascular system by detecting changes in left heart pressure which can detect possible development of pulmonary edema. 6. A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following should the nurse include to provide emotional support? A. Assign assistive personnel to keep his room neat and clean. Rationale: This intervention is important for infection control but does not address the client’s need for emotional support. B. Rotate nursing staff so he can have varied interactions. Rationale: This intervention inhibits the development of a trusting, nurse-client relationship which is an important component of providing emotional support. C. Talk with him during wound care. Rationale: Talking with the client while providing care assists in the development of the nurse-client relationship and demonstrates caring. D. Keep family members aware of his condition. Rationale: Detailed Answer Key RN 231 Quiz 4_Cloned_Assessment 1 Created on:04/06/2018 Page 4 This intervention does not address the client’s need for emotional support and may violate client confidentiality. 7. A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn? A. Age of the client Rationale: The client’s age is important in the assessment of the client’s burns, but is not the priority. B. Associated medical history Rationale: The client’s associated medical history is important in the assessment of the client’s burns, but is not the priority. C. Location of the burn Rationale:When using the urgent vs. nonurgent approach to care, the nurse determines the priority is to assess the location of the burns that may lead to respiratory distress. D. Cause of the burn Rationale: The client’s cause of the burns is important in the assessment of the client’s burns, but is not the priority. 8. A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hr following a burn injury? A. 5% dextrose in water Rationale: 5% dextrose in water is not the fluid used in the first 24 hr following a burn injury because a stress-induced pseudodiabetes often occurs after major burns and the administration of more dextrose would increase the possibility of hyperosmolar disease. B. 5% dextrose in normal saline Rationale: 5% dextrose in normal saline is not the fluid used in the first 24 hr following a burn injury because a stress-induced pseudodiabetes often occurs after major burns and the administration of more dextrose would increase the possibility of hyperosmolar disease. C. Normal saline Rationale: Normal saline is not the fluid used in the first 24 hr following a burn injury because the burn causes generalized increased capillary permeability and crystalloids leak out of the burn area into areas such as the pulmonary interstitial spaces and may cause pulmonary edema. D. Lactated Ringer’s Rationale: Lactated Ringer’s is a fluid used in the first 24 hr following a burn injury. Detailed Answer Key RN 231 Quiz 4_Cloned_Assessment 1 Created on:04/06/2018 Page 5 9. A nurse is caring for a client with burns to face, ears, and eyelids. Which of the following is the priority finding to report to the provider? A. Urinary output 25 mL/hr Rationale:While a urinary output of 25 mL/hr is below the expected output of 30 – 50 mL/hr and should be reported to the provider, this is not the priority finding to report. B. Difficulty swallowing Rationale: Difficulty swallowing is an indication that the client’s airway is becoming obstructed, and is the priority to report to the provider. C. Heart rate 122 beats/min Rationale: While a heart rate of 122 beats/min is above the expected reference range and should be reported to the provider, this is not the priority finding to report. D. Lip edema Rationale: While lip edema is not an expected finding and should be reported to the provider, this is not the priority finding to report. 10. A client arrives at the emergency department following an explosion at a chemical plant. He has deep partial- and full-thickness chemical burns over more than 25% of his body surface area. What is the nurse’s priority intervention for this client? A. Initiate fluid resuscitation. Rationale: The client will require fluid resuscitation, but this is not the highest priority at this time. B. Medicate for pain. Rationale: The client will require pain medication, but this is not the highest priority at this time. C. Administer antibiotics. Rationale: The client will require antibiotics, but this is not the highest priority at this time. D. Maintain a patent airway. Rationale: The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client’s airway patent, as the smoke and other irritants from the workplace explosion can cause swelling that can obstruct the trachea. 11. A nurse is planning care for a client who has a GI bleed. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure