TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 11TH EDITION BY HARDING Questions & Answers satisfaction guaranteed success ( CHAPTERS 21-29) latest update

TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 11TH EDITION BY HARDING Questions & Answers satisfaction guaranteed success ( CHAPTERS 21-29) latest update Test Bank MULTIPLE CHOICE 1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document theburn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destructionANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless becauseof the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibiterythema, blanching, and pain. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn hasthe following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion. ANS: C The patients laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patients fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 3. A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard,but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patients respiratory rate. d. Reposition the patient in high-Fowlers position and reassess breath sounds. ANS: B The patients history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriatebecause immediate action should occur. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 350 mL/hour b. 523 mL/hour c. 938 mL/hour d. 1250 mL/hourANS: C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other halfover the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output. ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patients weight is notuseful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintainadequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution. ANS: A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patients caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function,and is not routinely used in burn patients. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. While the patients fullthickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70 F (20 C) during dressing changes. ANS: B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85 Ffor patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurseshould place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck. ANS: B The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick tothe ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength andnumbness in the toes. Which action should the nurse take? need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation.Elevating the legs or increasing toe movement will not improve the patients circulation. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Whichnursing assessment would best evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult bloodANS: D H2 blockers and proton pump inhibitors are given to prevent Curlings ulcer in the patient who has sufferedburn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 11. The nurse is reviewing the medication administration record (MAR) on a patient with partial-thicknessburns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)ANS: D Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants toenhance the effects of opioids. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neckburns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is b. I will avoid using a pillow, so my neck will be OK. c. I bet my boyfriend wont even want to look at me anymore. d. Do you think dark beige makeup foundation would cover this scar on my cheek? ANS: D The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolutionof the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 13. The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine outputhas dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit. ANS: A The patients urine output indicates that the patient is entering the acute phase of the burn injury and moving onfrom the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires moretime. White blood cells may increase or decrease, based on the patients immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unitduring the acute stage of burn injury.