NCLEX Burns Critical Care exam 1

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Critical Care exam 1: respiratory Pra...

80 terms jackieD1514Preview Burn 22 terms cicil19Preview P2 DISASTER LEC SAS 9-Manageme...40 terms quizlette73479560 Preview Shock P 47 terms LeM A 40-year-old male client who was burned was admitted under your care. Assessment reveals he has crackles, respiratory rate of 40/min, and is coughing up blood- tinged sputum. What action will the nurse take first?

• Administer digoxin
• Perform chest physiotherapy
• Monitor urine output
• Place the client in an upright position
• Place the client in an upright position.

Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out.How will the nurse position a client with a burn wound to the posterior neck to prevent contractures?

• Have the client turn the head from side to side.
• Keep the client in a supine position without the use of

pillows.

• Keep the client in a semi-Fowler's position with her or

his arms elevated.

• Place a towel roll under the client's neck or shoulder.
• Have the client turn the head from side to side.

Deformities and contractures can often be prevented by proper positioning.Maintaining proper body alignment when the patient is in bed is vital. The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion. This movement is what would prevent contractures from occurring.On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action?

• Documenting the findings
• Loosening any dressings on the chest
• Raising the head of the bed
• Preparing for intubation
• Preparing for intubation.

Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose the effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway. The swelling usually precludes intubation.

Ten hours after the client with 50% burns is admitted, her blood glucose level is 142 mg/dL. What is the nurse's best action?

• Documents the finding
• Obtains a family history of diabetes
• Repeats the glucose measurement
• Stop IV fluids containing dextrose
• Documents the finding.

Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful.How will the nurse categorize this injury?

• Full-thickness
• Partial-thickness superficial
• Partial-thickness deep
• Full-thickness deep
• Partial-thickness deep.

Deep partial-thickness burns are pink or red in color, swollen, painful, with blisters that may ooze a clear fluid. Deep partial-thickness (second-degree) involves the deeper dermis. Healing occurs in 3 to 8 weeks with scarring present.The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client?

• Current range of motion in all extremities
• Heart rate and rhythm
• Respiratory rate and pulse oximetry reading
• Orientation to time, place, and person
• Heart rate and rhythm.

Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. It is also important to obtain the patient's cardiac history, including any history of prior arrhythmias.A 35-year-old male client was admitted due to severe burns around his right hip. Which position is most important to use to maintain the maximum function of this joint?

• Hip maintained in 30-degree flexion
• Hip at zero flexion with leg flat
• Knee flexed at 30-degree angle
• Leg abducted with a foam wedge
• Hip at zero flexion with leg flat.

The maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion.The client who is burned is drooling and having difficulty swallowing. Which action will the nurse take first?

• Assesses level of consciousness and pupillary

reactions

• Ascertains the time food or liquid was last consumed
• Auscultates breath sounds over the trachea and

mainstem bronchi

• Measures abdominal girth and auscultates bowel

sounds

• Auscultates breath sounds over the trachea and mainstem bronchi.

Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. The absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation.

A 12-year-old male with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide?

• "With reconstructive surgery, you can look the same."
• "We can remove the scars with the use of a pressure

dressing."

• "You will not look exactly the same."
• "You shouldn't start worrying about your appearance

right now."

• "You will not look exactly the same."

Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. Denial may be prolonged and be an adaptive mechanism because the patient is not ready to cope with personal problems.The client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3.Which is the nurse's best action?

• Continuing to monitor the client
• Increasing the temperature in the room
• Increasing the rate of the intravenous fluids
• Preparing to do a workup for sepsis
• Preparing to do a workup for sepsis.

These findings are associated with systemic gram-negative infection and sepsis.To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started.The family of a client who has been burned asks at what point the client will no longer be at greater risk for infection. What is the nurse's best response?

• "As soon as he finishes his antibiotic prescription."
• "As soon as his albumin level returns to normal."
• "When fluid remobilization has started."
• "When the burn wounds are closed."
• "When the burn wounds are closed."

Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open.The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first?

• Applies silver sulfadiazine (Silvadene) ointment
• Covers the area with an elastic wrap
• Places a synthetic dressing over the area
• Removes loose nonviable tissue
• Removes loose nonviable tissue.

The first step in this process is removing exudates and necrotic tissue. Burn patients are at high risk for infection, especially drug-resistant infection, which often results in significantly longer hospital stays, delayed wound healing, higher costs, and higher mortality Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action?

• Administers a laxative
• Documents the finding
• Increases the IV flow rate
• Repositions the client onto the right side
• Documents the finding.

Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this time.

Which information obtained by assessment ensures that the client's respiratory efforts are currently adequate?

• The client is able to talk.
• The client is alert and oriented.
• The client's oxygen saturation is 97%.
• The client's chest movements are uninhibited.
• The client's oxygen saturation is 97%.

Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?

• Emergent Phase
• Immediate Resuscitative Phase
• Acute Phase
• Rehabilitation Phase
• Acute Phase.

The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function.Infection prevention, burn wound care that includes wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting, pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections.