burns NCLEX style questions

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Teacher 179 terms angiepowell8989 Preview Burns Nclex style questions 152 terms S582643Preview Spinal Teacher julia the nurse has just received shift report for the burn unit. which client should she see first?

• the client who has just arrived from the ED with facial burns from a house fire

The nurse is performing a dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps in the order in which each should be accomplished.

• Apply silver sulfadiazine ointment.
• Obtain specimens for aerobic and anaerobic wound cultures.
• Administer morphine sulfate 10 mg IV.
• Debride the wound of eschar using gauze sponges.
• Cover the wound with a nonadherent gauze dressing.

3, 2, 4, 1, 5

Three burn patients have been admitted to the emergency room. In order of most importance, rank the patients according to who would be seen first, second and third by the nurse.

• a 45 year old patient who was in a house fire complaining of hoarseness
• a 30 year old female with bilateral circumferential burns to her lower extremities
• a 5 year old who is crying and has sustained a scald to their right palm

The nurse recognizes which etiology as consistent with a thermal burn?

• scalding

The nurse correlates which clinical manifestation to superficial partial-thickness burns?

• blisters

The nurse correlates which zone of burn injury as the most susceptible to sustained injury because of insufficient fluid resuscitation?

• zone of coagulation

The nurse recognizes that burns to which body areas meet the criteria for referral to a burn center because of the increased risk of functional changes? (Select all that apply)

• perineum
• elbows
• face
• hands

The nurse correlates which clinical manifestations to the possibility of an inhalation injury? (Select all that apply)

• facial and neck burns
• singed nasal hairs
• soot in sputum
• hoarseness
• wheezing

Using the Parkland Formula resuscitation guidelines, the nurse determines that a patient requires a total of 12 L of fluid in the first 24 hours post- injury. How much of the total volume needs to be given within the first 8 hours?

• 6,000mL LR

When hemodynamic status is monitored in a patient with a thermal burn injury, what amount of urine output indicates adequate fluid resuscitation?

• 0.5mL/kg/hr

The nurse recognizes which diagnostic test as most sensitive in a patient with a suspected electrical burn injury?

• creatinine kinase level

Which intervention is the priority for the patient during the emergent phase of burn management?

• use of clean, dry and warm blankets

The nurse anticipates supplementary feeding via a nasogastric tube in a patient for which reasons? (Select all that apply)

• hypermetabolic state
• multiple open wounds
• burn greater than 20%TBSA

A patient is admitted to the emergency room after sustaining an electrical burn with contact points to his right hand and left foot. The patient is being resuscitated with lactated Ringer’s solution using the Parkland formula. A urinary catheter was placed, and the nurse observes myoglobin in the urine along with a decrease in urine output. What is the most appropriate nursing action?

• notify the physician and anticipate increasing the IVF rate

A patient is admitted to the emergency room after sustaining a flash burn to his face. He presents with facial burns and singed nasal hair but is reporting no difficulty breathing. The nurse places the patient on 100% oxygen via face mask. Upon reassessment, the nurse notes that his voice has changed and the patient is reporting difficulty swallowing. What is the most appropriate nursing action?

• notify the physician and anticipate intubation

A 25-year-old male presents to the emergency room with a chemical burn to his hand. What is the nurse's first intervention?

• protect yourself, remove the patients clothing, wash out with copious amount of water

The client with an electrical burn injury is brought to the ED. The entrance wound is on the right hand and the exit wound is on the left foot.Which intervention should the nurse implement first?

• place the patient on telemetry

A patient weighing 242lbs. sustains a thermal burn at 1400 covering approximately 50% TBSA. The patient arrived in the emergency department at 1700. The patient is a young healthy male with no medical history. Using the Parkland formula, calculate the starting hourly infusion rate?

• 1,100 mL/hr

Which of the following statements is correct regarding burn classification? (Select all that apply)

• Deep partial-thickness injuries involve destruction of epidermis and deeper into the dermis.
• Superficial partial-thickness burns involve destruction of the epidermis and a small part of the dermis.
• Superficial burns involve only the epidermis.

In caring for patient with 50% total body surface area burns, the nurse correlates which finding to resolution of burn shock?

• UOP 800mL over 2 hrs

In providing care to a victim of a car fire who is confused, dizzy, and nauseated, the nurse recognizes the need for which diagnostic test to determine if this patient is experiencing carbon monoxide poisoning?

• carboxyhemoglobin level

The nurse is caring for a patient with 45% total body surface area thermal burns in the emergent phase. The nurse monitors for which laboratory result?

• increased potassium

An adult patient received burns over both upper and lower arms, anterior upper and lower legs, anterior chest, and face. Using the following as a guide, what is this patient's total body surface percentage of area burned?

49.5% TBSA

A client with a circumferential burn to the left lower extremity begins to complain of pain in the foot and calf. What is the nurse's first intervention?

• check pedal pulses

A nurse caring for a client who had a split-thickness meshed skin graft to the burned area on his leg, should include which of the following in the

client's plan of care: (Select all that apply)

• Elevate the affected extremity on pillows or with slings
• Immobilize the extremity

Perform vigorous active ROM to the extremity every 2 hours

• Remove any fluid collected under the graft

In patients with extensive burns, what process is responsible for edema occurring in both burned and unburned areas?

• increased capillary permeability

Why is silver used as an ingredient in many burn dressings?

• silver is effective against a wide spectrum of wound pathogens

Which of the following statements about the pain management of a burn victim are true? (Select all that apply)

• Additional pain medication may be needed because of rapid body metabolism.
• Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy.
• Patients with a history of drug and alcohol abuse could require higher doses of pain medication.

Which complications may manifest after an electrical injury? (Select all that apply)

• long bone fractures
• cardiac dysrhythmias
• compartment syndrome of extremities
• dark brown urine
• acute cataract formation
• seizures

Which of the following effects of major burn injury are contributing factors to decreased cardiac output? SATA

• Hemoconcentration
• Catecholamine release
• Increased capillary permeability
• Hypermetabolic state

Which of the following orders would the nurse anticipate to be ordered during the emergent phase of burn care? SATA

• Place an NGT
• Obtain baseline labs
• Monitor UOP/VS every hour
• Obtain a chest x-ray Terms (31)

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