exam 3 practice
Multiple Choice
Identify the choice that best completes the statement or answers the question.
_ 1. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? 2. A nurse cares for a client who has facial burns. The client asks, “Will I ever look the same?” How
should the nurse respond?
a. “With reconstructive surgery, you can look the same.”
b. “We can remove the scars with the use of a pressure dressing.”
c. “You will not look exactly the same but cosmetic surgery will help.”
d. “You shouldn’t start worrying about your appearance right now.”
3. An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air. 4. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn
injury. The client asks, “Why am I taking this medication?” How should the nurse respond?
a. “Tagamet stimulates intestinal movement so you can eat more.”
b. “It improves fluid retention, which helps prevent hypovolemic shock.”
c. “It helps prevent stomach ulcers, which are common after burns.”
d. “Tagamet protects the kidney from damage caused by dehydration.”
5. A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds. _ 6. A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid
resuscitation per the Parkland formula. The client’s urine output continues to range from 0.2 to
0.25 mL/kg/hr. Which prescription should the nurse question?
a. Increase intravenous fluids by 100 mL/hr.
b. Administer furosemide (Lasix) 40 mg IV push.
c. Continue to monitor urine output hourly.
d. Draw blood for serum electrolytes STAT.
a. Use a disposable blood pressure cuff to avoid sharing with other clients.
b. Change gloves between wound care on different parts of the client’s body.
c. Use the closed method of burn wound management for all wound care.
d. Advocate for proper and consistent handwashing by all members of the staff.
_ 7. A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L 8. A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a
respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action
should the nurse take next?
a. Administer furosemide (Lasix).
b. Perform chest physiotherapy.
c. Document and reassess in an hour.
d. Place the client in an upright position.
9. A nurse cares for a client who has burn injuries. The client’s wife asks, “When will his high risk for infection decrease?” How should the nurse respond? a. “When the antibiotic therapy is complete.” b. “As soon as his albumin levels return to normal.” c. “Once we complete the fluid resuscitation process.” d. “When all of his burn wounds have closed.” 10. A nurse administers topical gentamicin sulfate (Garamycin) to a client’s 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
11. A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client’s pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries. 12. A nurse cares for a client with burn injuries from a house fire. The client is not consistently
oriented and reports a headache. Which action should the nurse take?
a. Increase the client’s oxygen and obtain blood gases.
b. Draw blood for a carboxyhemoglobin level.
c. Increase the client’s intravenous fluid rate.
d. Perform a thorough Mini-Mental State Examination.
___ 13. A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse
include in this client’s discharge teaching?
a. “You should change the batteries in your smoke detector once a year.”
b. “Join a program that assists burn clients to reintegration into the community.”
c. “I will demonstrate how to change your wound dressing for you and your family.”
d. “Let me tell you about the many options available to you for reconstructive
surgery.”
_ 14. 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-Fowler’s position. d. Gather appropriate equipment and prepare for an emergency airway. 15. A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left
arm. How should the nurse document the percentage of the client’s body that sustained burns?
a. 9%
b. 18%
c. 27%
d. 36%
16. 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) 17. A nurse reviews the following data in the chart of a client with burn injuries:
Admission Notes Wound Assessment
36-year-old female with bilateral leg burns
NKDA
Health history of asthma and seasonal
allergies
Bilateral leg burns present with a white
and leather-like appearance. No
blisters or bleeding present. Client
rates pain 2/10 on a scale of 0-10.
Based on the data provided, how should the nurse categorize this client’s injuries?
a. Partial-thickness deep
b. Partial-thickness superficial
c. Full thickness
d. Superficial
___ 18. After assessing an older adult client with a burn wound, the nurse documents the findings as
follows:
Vital Signs Laboratory Results Wound Assessment
Heart rate: 110 beats/min
Blood pressure: 112/68 mm
Hg
Respiratory rate: 20
breaths/min
Oxygen saturation: 94%
Pain: 3/10
Red blood cell count:
5,000,000/mm3
White blood cell count:
10,000/mm3
Platelet count: 200,000/mm3
Left chest burn wound, 3
cm 2.5 cm 0.5 cm,
wound bed pale,
surrounding tissues with
edema present
Based on the documented data, which action should the nurse take next?
a. Assess the client’s skin for signs of adequate perfusion.
b. Calculate intake and output ratio for the last 24 hours.
c. Prepare to obtain blood and wound cultures.
d. Place the client in an isolation room.
_ 19. A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client’s mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP. 20. A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12 to 18
breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4
hours ago. What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess the client’s tissue perfusion further.
c. Document the findings in the client’s chart.
d. Increase the rate of the client’s IV infusion.
21. The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours 22. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3
,
blood glucose level 198 mg/dL, and temperature 96.2° F (35.6° C). What action by the nurse takes
priority?
a. Document the findings in the client’s chart.
b. Give the client warmed blankets for comfort.
c. Notify the health care provider immediately.
d. Prepare to administer insulin per sliding scale.
23. A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed. 24. A client arrives in the emergency department after being in a car crash with fatalities. The client
has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters.
___ 25. A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates
a therapeutic effect from this drug?