Emergency/Burns/Shock Practice Questions

Emergency/Burns/Shock Practice Questions Leave the first rating Students also studied Terms in this set (17) Science MedicineNursing Save NCLEX Emergency/Burns/Triage 93 terms Nurse_Ratched_2020 Preview Chapter 25 Burns NCLEX style quest...22 terms Amanda_Washington7 Preview NCLEX Style Practice Questions Bur...100 terms akrrissman84Preview Emerge 38 terms lear The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

• A postoperative client preparing for discharge with a

new medication

• A client requiring daily dressing changes of a recent

surgical incision

• A Client scheduled for a chest x-ray after insertion of a

nasogastric tube

• A client with asthma who requested a

breathingtreatment during the previous shift

• A client with asthma who requested a breathingtreatment during the previous

shift The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

• A client complaining of muscle aches, a head- ache,

and history of seizures

• A client who twisted her ankle when rollerblad- ing and

is requesting medication for pain

• A client with a minor laceration index finger sustained

while cutting an eggplant

• A Client with chest pain who states that he just ate

pizza that was made with a very spicy sauce

• A Client with chest pain who states that he just ate pizza that was made with a

very spicy sauce

The nurse is monitoring a child with burns during treatment for burn shock. Which assessment pro- vides the most accurate guide to determine the adequacy of fluid resuscitation?

• Skin turgor
• Level of edema at burn site
• Adequacy of capillary filling
• Amount of fluid tolerated in 24 hours
• Adequacy of capillary filling

The nurse caring for a child who sustained a burn injury plans care based on which pediatric consid- erations associated with this injury? Select all that apply.

• Scarring is less severe in a child than in an adult.
• A delay in growth may occur after a burn injury.
• An immature immune system presents an increased risk

of infection for infants and young children.

• Fluid resuscitation is unnecessary unless the burned

area is more than 25% of the total body surface area.

• The lower proportion of body fluid to body mass in a

child increases the risk of cardio- vascular problems.

• Infants and young children are at increased risk for

protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

• A delay in growth may occur after a burn injury.
• An immature immune system presents an increased risk of infection for infants

and young children.

• Infants and young children are at increased risk for protein and calorie

deficiency because they have smaller muscle mass and less body fat than adults.The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occur- rence is which action?

• Immobilize the affected extremity.
• Remove jewelry and constricting clothing from the

victim.

• Place the extremity in a position so that it is below the

level of the heart.

• Move the victim to a safe area away from the snake and

encourage the victim to rest.

• Move the victim to a safe area away from the snake and encourage the victim to

rest.A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?

• "Come to the emergency department."
• "Apply calamine lotion immediately to the exposed skin

areas."

• "Take a shower immediately, lathering and rins- ing

several times."

• "It is not necessary to do anything if you cannot see

anything on your skin."

• "Take a shower immediately, lathering and rins- ing several times."

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?

• A pink, edematous hand
• Fiery red skin with edema in the nail beds
• Black fingertips surrounded by an erythematous rash
• A white color to the skin which is sensitive to touch
• A white color to the skin which is sensitive to touch

An adult client was burned in an explosion. The burn initially affected the client's entire face (ante- rior half of the head) and the upper half of the ante- rior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subse- quent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

1. 18%

2. 24%

3. 36%

4. 48%

3. 36%

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?

• Return of distal pulses
• Brisk bleeding from the site
• Decreasing edema formation
• Formation of granulation tissue
• Return of distal pulses

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mm Hg, a pulse rate of 110 beats/minute, and a urine out- put of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription?

• Transfusing 1 unit of packed red blood cells
• Administering a diuretic to increase urine output
• Increasing the amount of intravenous (IV) lactated

Ringer's solution administered per hour

• Changing the IV lactated Ringer's solution to one that

contains 5?xtrose in water

• Increasing the amount of intravenous (IV) lactated Ringer's solution

administered per hour

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.

• Restrict fluids.
• Assess for airway patency.
• Administer oxygen as prescribed.
• Place a cooling blanket on the client.
• Elevate extremities if no fractures are present

.6. Prepare to give oral pain medication as prescribed

• Assess for airway patency.
• Administer oxygen as prescribed.
• Elevate extremities if no fractures are present

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

• Decreased heart rate
• Increased urinary output
• Increased blood pressure
• Elevated hematocrit levels
• Elevated hematocrit levels

A client arrives at the emergency department fol- lowing a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed?

• 100% oxygen via an aerosol mask
• Oxygen via nasal cannula at 6 L/minute
• Oxygen via nasal cannula at 15 L/minute
• 100% oxygen via a tight-fitting, nonrebreather face

mask

• 100% oxygen via a tight-fitting, nonrebreather face mask

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial- thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?

• Vital signs
• Urine output
• Mental status
• Peripheral pulses
• Urine output

The nurse manager is observing a new nursing grad- uate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe com- ponent of protective isolation technique?

• Using sterile sheets and linens
• Performing strict hand-washing technique
• Wearing gloves and a gown only when giving direct

care to the client

• Wearing protective garb, including a mask, gloves, cap,

shoe covers, gowns, and plastic apron

• Wearing gloves and a gown only when giving direct care to the client