Burns/NCLEX QUESTIONS kidniki77 Save NCLEX Style Practice Questions Bur...100 terms akrrissman84Preview Nclex Questions for Shock - Critical ...32 terms karmageniePreview Burns NCLEX questions Teacher 122 terms NJAMfRNPreview NCLEX 25 terms Lau The burn nurse is aware that wound care during the acute phase involves consideration of which of the following?
- First and superficial second-degree burns can usually be managed with clean technique.
- Deep second-degree burns with or without impaired circulation heal without surgical intervention.
- Full thickness burns require surgical intervention to heal.
- The presence of infection is a contraindication to surgical wound management.
- Full thickness burns require surgical intervention to heal.
- The hypermetabolic state lasts from 9-12 months following burn injury and body weight requires carefully monitoring.
- Extensive burn injury decreases the risk for developing bone density changes.
- Thermoregulation disturbances may result in an inability to adjust to changes in environment temperatures.
- The hypermetabolic state lasts from 9-12 months following burn injury and body weight requires carefully monitoring.
- There is evidence of tautness, decreased capillary refill, coolness and decreased pulses.
- The edema is the area is rapidly dissipating resulting in hypoperfusion to the extremity.
- There is increased discomfort in the affected area.
- There is evidence of tautness, decreased capillary refill, coolness and decreased pulses.
During the rehabilitation phase, the physical healing focuses primarily on wound healing. The burn nurse includes which the following in patient education to assist the patient and family for their return to the community?a.The immune system heals along with the skin and future risk of infection stabilizes.
When evaluating the burn extremity for the development of compartment syndrome, which signs and symptoms would alert the nurse to the possibility this has developed??a.The presence of burn eschar that covers the entire lateral surface of the extremity.
While monitoring a burn victim, which of the following is considered the 'gold standard' to evaluate burn resuscitation?
- A heart rate less than 120 beats per minute, a blood pressure that is normal to slightly hypertensive and clear lung sounds.
- An adult urine output that is approximately 0.5-1.0ml/kg/hour.
- A pulmonary capillary wedge pressure of less than 18 mm Hg.
- A urinary output has been adequate for 2 hours.
- An adult urine output that is approximately 0.5-1.0ml/kg/hour
- 20,160 milliliters.
- 5,040 milliliters.
- 2520 milliliters.
- 5,040 milliliters
- Impaired Gas Exchange related to inhalation injury.
- Ineffective airway clearance related to inhalation injury.
- Deficient fluid Volume related to third spacing of fluids.
- Pain related to burn injury.
- Ineffective airway clearance related to inhalation injury.
- Progressive stridor and hoarseness.
- Singed chest hairs.
- Increased body temperature.
- Progressive stridor and hoarseness
- Edema formation can be expected in the burn area as a compensatory process from the microcirculation.
- Hypovolumia, slowed capillary circulation and hyperviscosity are evident.
- Increased tissue perfusion in the wound area to attempt to maintain tissue viability in the affected area.
- Peripheral vasodilation decreases perfusion in the affected area.
- Hypovolumia, slowed capillary circulation and hyperviscosity are evident
Using the Parkland formula calculate the fluid volume for a 154 woman who has sustained a 36% mixed deep partial and full thickness burn. How much fluid would you administer during the first 8 hours of fluid resuscitation?a.10,080 milliliters.
Which of the following nursing diagnoses for the patient with a burn Injury has the highest priority during the resuscitative phase?
The nurse is performing a primary burn assessment according to the ABCs (airway, breath, circulation) guidelines. Which of the following indicate signs and symptoms of inhalation injury?a.Facial swelling and bruising.
The nurse is assessing an Emergency Room patient for evidence of cardiovascular changes associated with deep and full thickness burns. Which of the following would indicate cardiovascular changes as a result of a serious burn?
Which of the following dysfunctions can the nurse anticipate in the burn patient with deep partial or full thickness injury?
- There is retention of the ability of the skin to regulate core temperature.
- There is increased risk of infection due to a loss of integrity of a primary barrier.
- There is a decreased sensitivity to ultraviolet radiation.
- There is maintenance of the ability to absorb Vitamin D.
- There is increased risk of infection due to a loss of integrity of a primary barrier
- There is no change in capillary refill in the injured extremity.
- Hair follicles, sebaceous glands and epidermal sweat glands are intact.
- The wound appearance is a waxy white, with a wet surface and fluid filled blisters.
- The wound is very painful.
- The wound appearance is a waxy white, with a wet surface and fluid filled blisters.
- Fat, tendons, and bones
- Skin and hair
- Nerves, muscle, and blood vessels
- Skin, fat, and muscle
- Fat, tendons, and bones
- Glucose 100 mg/dL
- Potassium 3.5 mEq/L
- Sodium 142 mEq/L
- Albumin 4.2 gm/dL
- Glucose 100 mg/dL
- Erythrocyte sedimentation rate
- Indirect Coombs
- C reactive protein
- Sickledex
- Sickledex
The nurse is assessing a patient who has sustained a suspected deep partial thickness burn. In determining if this is a superficial or deep partial thickness injury, the nurse would anticipate which of the following? (Select all that apply.)
The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury?
Which laboratory result would be expected during the emergent phase of a burn injury?
An African American client is admitted with full thickness burns over 40% of his body. In addition to the CBC and complete metabolic panel, the physician is likely to request which additional blood-work?
A client weighing 76 kg is admitted at 0600 with a TBSA burn of 40%. Using the Parkland formula, the client's 24-hour intravenous fluid
replacement should be:
- 6,080 mL
- 9,120 mL
- 12,160 mL
- 15,180 mL
- 12,160 mL
On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify
the doctor for an order to:
- Decrease the rate of the intravenous infusion.
- Change the type of intravenous fluid being administered.
- Change the urinary catheter.
- Increase the rate of the intravenous infusion.
- Increase the rate of the intravenous infusion
- Isograft
- Autograft
- Homograft
- Xenograft
- Xenograft
A Jewish client requires grafting to promote burn healing. Which graft is most likely to be unacceptable to the client?
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the
client is:
- Silver sulfadiazine (Silvadene)
- Poviodine (Betadine)
- Mafenide acetate (Sulfamylon)
- Silver nitrate
- Mafenide acetate (Sulfamylon)
- Needs additional fluids
- Has a normal CVP reading
- May show signs of congestive failure
- Would benefit from a diuretic
- Has a normal CVP reading
The CVP reading of a client with partial thickness burns is 6 mm H2O. The nurse recognizes that the client:
The physician has prescribed Protonix (pantoprazole) for a client with burns. The nurse recognizes that the medication will help prevent the
development of:
- Curling's ulcer
- Myoglobinuria
- Hyperkalemia
- Paralytic ileus
- Curling's ulcer