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Exam (elaborations)

Sherpath Questions with CORRECT Answers (Verified Update)

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Sherpath Questions with CORRECT Answers (Verified Update)

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Sherpath Questions with CORRECT Answers (Verified Update)

Q1: Which intervention would the nurse plan to perform during the resuscitative phase when
treating a patient with a thermal burn injury? Select all that apply. One, some, or all answers
may be correct.
A. Assess for signs of airway edema.
B. Begin mechanical ventilation.
C. Administer fluid replacement.
D. Perform skin grafting to close the wound.
E. Assist with range of motion to prevent contractures.
Answer: A. Assess for signs of airway edema.
B. Begin mechanical ventilation.
C. Administer fluid replacement.


Q2: Which finding would the nurse expect to assess in a patient with upper airway inhalation
injury?
A. Decreased HbCO levels
B. Scattered basilar crackles
C. Respiratory rate of 10 breaths/min
D. Heart rate of 125 beats/min
Answer: D. Heart rate of 125 beats/min


Q3: When assessing a patient receiving mechanical ventilation for thermal burns and inhalation
injury, which finding would indicate readiness for extu- bation? Select all that apply. One,
some, or all answers may be correct.
A. Inspiratory stridor
B. Absent gag reflex
C. Negative inspiratory force of -15 cm H2O
D. Vital capacity of 15 mL/kg
E. Decreased tenacity of sputum
Answer: D. Vital capacity of 15 mL/kg


Q4: A patient should have decreased volume and tenacity of sputum prior to extubation. Which
fluid solution would the nurse plan to administer to a patient with sig- nificant third spacing
and tissue edema 24 hours after admission for thermal burns?
A. Lactated Ringer
B. Normal saline
C. 5% Dextrose in lactated Ringer
D. Albumin
Answer: D. Albumin

, Q5: Which fluid solution would the nurse plan to administer to a patient with sig- nificant third
spacing and tissue edema 24 hours after admission for thermal burns?
A. Lactated Ringer
B. Normal saline
C. 5% Dextrose in lactated Ringer
D. Albumin
Answer: D. Albumin


Q6: When caring for a 75-kg patient with thermal burns, which assessment finding would indicate
adequate fluid resuscitation? Select all that apply. One, some, or all answers may be correct.
A. Urine output of 30 mL/h
B. Heart rate of 125 beats/min
C. Blood pressure of 132/84 mm Hg
D. Clear lung sounds
E. Altered mental status
Answer: C. Blood pressure of 132/84 mm Hg


Q7: A patient with adequate fluid resuscitation would have clear lung sounds and sensorium.
Which intervention would the nurse implement to reduce the risk of infec- tion in a patient
with full-thickness burns to 21% of the body?
A. Administer prophylactic antibiotics.
B. Change gloves when moving between areas during wound care.
C. Implement airborne precautions.
D. Limit shared topical agents to no more than two patients.
Answer: B. Change gloves when moving between areas during wound care.


Q8: Which intervention would the nurse implement to reduce the risk of infec- tion in a patient
with full-thickness burns to 21% of the body?
A. Administer prophylactic antibiotics.
B. Change gloves when moving between areas during wound care.
C. Implement airborne precautions.
D. Limit shared topical agents to no more than two patients.
Answer: B. Change gloves when moving between areas during wound care.

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