NURS 241- EXAM 3 Violence, Human trafficking, & Burns
Questions With Complete Solutions
. A nurse assesses bilateral wheezes in a client with burn injuries
inside the mouth. Four hours later the wheezing is no longer
heard. Which action should the nurse take?
a. Document the findings and reassess in 1 hour.
b. Loosen any constrictive dressings on the chest.
c. Raise the head of the bed to a semi-Fowlers position.
d. Gather appropriate equipment and prepare for an emergency
airway. Correct Answers d. Gather appropriate equipment and
prepare for an emergency airway.
* Clients with severe inhalation injuries may sustain such
progressive obstruction that they may lose effective movement
of air. When this occurs, wheezing is no longer heard, and
neither are breath sounds. These clients can lose their airways
very quickly, so prompt action is needed. The client requires
establishment of an emergency airway. Swelling usually
precludes intubation. The other options do not address this
emergency situation.
1. The client asks about ways to prevent carbon monoxide
poisoning. Which teaching will the nurse provide?
a. "You can see black smoke when carbon monoxide is in the
air."
b. "If you are experiencing carbon monoxide poisoning, your
skin will begin turning blue."
c. "The only way to get poisoned from carbon monoxide gas is if
you are in the presence of a fire."
,d. "It is important to have carbon monoxide detectors in your
home, because this is an odorless gas." Correct Answers d. "It
is important to have carbon monoxide detectors in your home,
because this is an odorless gas."
*Carbon monoxide is a colorless, odorless gas; it can be present
in environments other than those associated with a fire.
Exposure turns skin cherry red. Having carbon monoxide
detectors in the home can decrease the likelihood of exposure to
this gas, if it is generated as the result of a fire, or as a result of a
gas leak from appliances.
A 30 yr old femal has full thickness burns on the legs & arms.
As a nurse, you know this pt is at risk for which of the
following? (select all that apply)
a) infection
b) nutrition imbalance
c) electrolyte imbalance
d) addison's
e) SIADH
f) DI Correct Answers a) infection
b) nutrition imbalance
c) electrolyte imbalance
e) SIADH
A female patient arrives at the emergency department visibly
upset and tearful. She refuses to have a male caregiver, asks for
a room close to an exit door, and does not make eye contact with
staff. What does the nurse suspect is happening with the patient?
a) The patient may be having an acute psychotic episode related
to her mental illness.
,b) The patient may be abusing street drugs and needs a drug
screening test.
c) The patient may have been the victim of an acute assault.
d) The patient may be a very demanding and particular person.
Correct Answers c) The patient may have been the victim of an
acute assault.
*Refusing care from a caregiver of another gender, wanting easy
escape access, and having poor eye contact all indicate that an
assault may have occurred. Acute psychosis, use of street drugs,
or being a demanding person does not elicit the signs of wanting
to protect herself from others.
A new case management nurse has been hired at a nursing home
to investigate several recent resident deaths at the facility. The
nurse understands that because there are many kinds of potential
abuse, she will need to assess for what type of factors?
a) High ratio of overweight residents
b) Unexplained bruising of residents
c) Altered cognitive function of residents
d) Skin breakdown in residents resulting from poor hygiene
e) Documentation of prescribed physical therapy sessions
Correct Answers b) Unexplained bruising of residents
c) Altered cognitive function of residents
d) Skin breakdown in residents resulting from poor hygiene
*In addition to psychological signs such as depression, signs of
elder abuse include bruising from physical abuse and skin
breakdown from neglect of hygiene and nutrition; frailty and
decreased cognitive function are also risk factors for abuse.
, Overweight residents and following prescribed treatments are
not indicators of abuse or neglect.
A nurse administers topical gentamicin sulfate (Garamycin) to a
clients burn injury. Which laboratory value should the nurse
monitor while the client is prescribed this therapy?
a. Creatinine
b. Red blood cells
c. Sodium
d. Magnesium Correct Answers a. Creatinine
*Gentamicin is nephrotoxic, and sufficient amounts can be
absorbed through burn wounds to affect kidney function. Any
client receiving gentamicin by any route should have kidney
function monitored. Topical gentamicin will not affect the red
blood cell count or the sodium or magnesium levels.
A nurse assesses a client admitted with deep partial-thickness
and full-thickness burns on the face, arms, and chest. Which
assessment finding should alert the nurse to a potential
complication?
a. Partial pressure of arterial oxygen (PaO2 ) of 80 mm Hg
b. Urine output of 20 mL/hr
c. Productive cough with white pulmonary secretions
d. Core temperature of 100.6 F (38 C) Correct Answers b.
Urine output of 20 mL/hr
* A significant loss of fluid occurs with burn injuries, and fluids
must be replaced to maintain hemodynamics. If fluid
replacement is not adequate, the client may become hypotensive
and have decreased perfusion of organs, including the brain and
Questions With Complete Solutions
. A nurse assesses bilateral wheezes in a client with burn injuries
inside the mouth. Four hours later the wheezing is no longer
heard. Which action should the nurse take?
a. Document the findings and reassess in 1 hour.
b. Loosen any constrictive dressings on the chest.
c. Raise the head of the bed to a semi-Fowlers position.
d. Gather appropriate equipment and prepare for an emergency
airway. Correct Answers d. Gather appropriate equipment and
prepare for an emergency airway.
* Clients with severe inhalation injuries may sustain such
progressive obstruction that they may lose effective movement
of air. When this occurs, wheezing is no longer heard, and
neither are breath sounds. These clients can lose their airways
very quickly, so prompt action is needed. The client requires
establishment of an emergency airway. Swelling usually
precludes intubation. The other options do not address this
emergency situation.
1. The client asks about ways to prevent carbon monoxide
poisoning. Which teaching will the nurse provide?
a. "You can see black smoke when carbon monoxide is in the
air."
b. "If you are experiencing carbon monoxide poisoning, your
skin will begin turning blue."
c. "The only way to get poisoned from carbon monoxide gas is if
you are in the presence of a fire."
,d. "It is important to have carbon monoxide detectors in your
home, because this is an odorless gas." Correct Answers d. "It
is important to have carbon monoxide detectors in your home,
because this is an odorless gas."
*Carbon monoxide is a colorless, odorless gas; it can be present
in environments other than those associated with a fire.
Exposure turns skin cherry red. Having carbon monoxide
detectors in the home can decrease the likelihood of exposure to
this gas, if it is generated as the result of a fire, or as a result of a
gas leak from appliances.
A 30 yr old femal has full thickness burns on the legs & arms.
As a nurse, you know this pt is at risk for which of the
following? (select all that apply)
a) infection
b) nutrition imbalance
c) electrolyte imbalance
d) addison's
e) SIADH
f) DI Correct Answers a) infection
b) nutrition imbalance
c) electrolyte imbalance
e) SIADH
A female patient arrives at the emergency department visibly
upset and tearful. She refuses to have a male caregiver, asks for
a room close to an exit door, and does not make eye contact with
staff. What does the nurse suspect is happening with the patient?
a) The patient may be having an acute psychotic episode related
to her mental illness.
,b) The patient may be abusing street drugs and needs a drug
screening test.
c) The patient may have been the victim of an acute assault.
d) The patient may be a very demanding and particular person.
Correct Answers c) The patient may have been the victim of an
acute assault.
*Refusing care from a caregiver of another gender, wanting easy
escape access, and having poor eye contact all indicate that an
assault may have occurred. Acute psychosis, use of street drugs,
or being a demanding person does not elicit the signs of wanting
to protect herself from others.
A new case management nurse has been hired at a nursing home
to investigate several recent resident deaths at the facility. The
nurse understands that because there are many kinds of potential
abuse, she will need to assess for what type of factors?
a) High ratio of overweight residents
b) Unexplained bruising of residents
c) Altered cognitive function of residents
d) Skin breakdown in residents resulting from poor hygiene
e) Documentation of prescribed physical therapy sessions
Correct Answers b) Unexplained bruising of residents
c) Altered cognitive function of residents
d) Skin breakdown in residents resulting from poor hygiene
*In addition to psychological signs such as depression, signs of
elder abuse include bruising from physical abuse and skin
breakdown from neglect of hygiene and nutrition; frailty and
decreased cognitive function are also risk factors for abuse.
, Overweight residents and following prescribed treatments are
not indicators of abuse or neglect.
A nurse administers topical gentamicin sulfate (Garamycin) to a
clients burn injury. Which laboratory value should the nurse
monitor while the client is prescribed this therapy?
a. Creatinine
b. Red blood cells
c. Sodium
d. Magnesium Correct Answers a. Creatinine
*Gentamicin is nephrotoxic, and sufficient amounts can be
absorbed through burn wounds to affect kidney function. Any
client receiving gentamicin by any route should have kidney
function monitored. Topical gentamicin will not affect the red
blood cell count or the sodium or magnesium levels.
A nurse assesses a client admitted with deep partial-thickness
and full-thickness burns on the face, arms, and chest. Which
assessment finding should alert the nurse to a potential
complication?
a. Partial pressure of arterial oxygen (PaO2 ) of 80 mm Hg
b. Urine output of 20 mL/hr
c. Productive cough with white pulmonary secretions
d. Core temperature of 100.6 F (38 C) Correct Answers b.
Urine output of 20 mL/hr
* A significant loss of fluid occurs with burn injuries, and fluids
must be replaced to maintain hemodynamics. If fluid
replacement is not adequate, the client may become hypotensive
and have decreased perfusion of organs, including the brain and
