NUR 265 Exam 3 Questions With Verified Answers Latest Updated 2024/2025 Graded A+.

NUR 265 Exam 3 Questions With Verified Answers Latest Updated 2024/2025 Graded A+. Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this Three days after a burn injury, the client develops a temperature of 100° F, white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which - Correct Answer -Wound infection wound to the LPN. Which instruction is most important for the RN to provide the LPN? - Correct Answer -Wash hands upon entering the clients room What intervention will the nurse implement to reduce a client's pain after a burn injury? - Correct Answer -Administer 4mg Morphine IV What statement indicates the client needs further education regarding the skin grafting (allografting)? - Correct Answer -"Because the graft is my own skin, there is no chance it won't 'take.' When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? - Correct Answer -Changing gloves between wound care on different parts of the client's body Which assessment finding assists the nurse in confirming inhalation injury? - Correct Answer -Brassy cough Which finding indicates that fluid resuscitation has been successful for a client with a burn injury? - Correct Answer -Urine output = 50ml/HR Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance? - Correct Answer -Performing his own morning care. Why? Indicators that the client with a burn injury has a positive perception of his appearance includes the willingness to touch the affected body part. Self-care activities such as NUR 265 Exam 3 Questions and Answers Latest Updated 2024/2025 /A+ Graded morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the Which finding indicates to the nurse that the client understands the psychosocial impact of his severe burn injury? - Correct Answer -It is normal to feel depressed. Which finding is characteristic during the emergent period after a deep full thickness burn injury? - Correct Answer -Urine output of 10ml/hr Why? During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreaseD. Foulsmelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns. Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain? - Correct Answer -Decreased tissue perfusion Why? During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury and a disrupted breathing pattern. Disturbed body image and disuse syndrome can develop. However, these are not priority diagnoses at this time. Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report to the physician immediately? - Correct Answer -Serum potassium,7.5 mmol/L (mEq/L) Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury? - Correct Answer -Allowing the client to eat whenever he or she wants Why? Clients should request food whenever they think that they can eat, not just according to the hospital's standard meal schedule. The nurse needs to work with a nutritionist to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications. hich statement best exemplifies the client's understanding of rehabilitation after a fullthickness burn injury? - Correct Answer -"My goal is to achieve the highest level of functioning that I can"