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Burn Injury: NCLEX Questions
Leave the first rating Students also studied Terms in this set (16) Science MedicineNursing Save Pancreatitis, NCLEX 59 terms melissa-knight Preview burns NCLEX style questions 31 terms elizabeth_turk Preview ATI Civility Mentor Module Quiz 2 10 terms kodie_searsPreview Burns/ 20 terms kidn When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?Full-thickness skin destruction
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On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn
has the 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 of the following prescribed actions should be the nurse's priority?Increasing the rate of the ordered IV solution
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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 action should the nurse take?Notify the health care provider and prepare for endotracheal intubation.
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given 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?938 mL/hr - Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr
During the emergent phase of burn care, which assessment is most useful in determining whether the patient is receiving adequate fluid infusion?Measure hourly urine output
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?Insert a feeding tube and initiate enteral nutrition.
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Which nursing action prevents cross contamination when the patient's full-thickness burn wounds to the face are exposed?Wearing gown, cap, mask, and gloves during care.
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?Elevate the right arm and hand on pillows and extend the fingers.
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first?Notify the health care provider.
Esomeprazole is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?Stool occult blood
Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns?hydromorphone (Dilaudid)
A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has been having difficulty with body image over the past several months. Which statement by the patient best indicates that the problem is resolving?"Do you think dark beige makeup will cover this scar?"
A patient admitted with burns over 30% of the body surface 2 days ago now has dramatically increased urine output. Which action should the nurse plan to support maintaining kidney function?Continuing to measure the urine output.
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment.Which snack would be best for the nurse to offer to this patient?Vanilla milkshake
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?Extremity movement - All patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data.
An employee spills industrial acid on both arms and legs at work. What action should the occupational health nurse take?Remove nonadherent clothing and wristwatch - With chemical burns, the first action is to remove the chemical from contact with the skin as quickly as possible.
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