NUR 265 Exam 3
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action? Correct Answer: Document the findings
Why?
Decreased or absent peristalsis is an expected response during the emergent phase of burn ...
twelve hours after the client was initially burned
bowel sounds are absent in all four abdominal quadrants which is the nurses best
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NUR 265 Exam 3
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal
quadrants. Which is the nurse's best action? Correct Answer: Document the findings
Why?
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 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. Foul-smelling 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 full-thickness burn
injury? Correct Answer: "My goal is to achieve the highest level of functioning that I can"
Which statement indicates that a client with facial burns understands the need to wear a facial pressure
garment? Correct Answer: "My facial scars will be less with the use of this facial mask"
he client with a dressing covering the neck is experiencing some respiratory difficulty. What is the
nurse's best first action Correct Answer: Loosen the dressing
During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before
dressing the wound. The client has all the following manifestations. Which manifestation indicates that
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