LIPPINCOTTS NCLEX RN REVIEW FOR MED

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LIPPINCOTTS NCLEX RN REVIEW FOR MED

SURG TEST 1 AND PEARSON EXAM CRAM

NCLEX RN TEST 1 MED SURG COMPLETE 450

QUESTIONS WITH DETAILED SOLUTIONS JUST

RELEASED THIS YEAR

LIPPINCOTTS NCLEX RN REVIEW EXAM

Question: 1. The nurse should plan to begin rehabilitation

efforts for the burn client:

• 1. Immediately after the burn has occurred.• 2. After the client's circulatory status has been stabilized.• 3. After grafting of the burn wounds has occurred.• 4. After the client's pain has been eliminated. - CORRECT ANSWER✔✔1 0 . 2 . Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will 1 / 4

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2 be able to make the adjustments necessary to return to an optimal state of health and independence. It is not possible to completely eliminate the client's pain; pain control is a major challenge in burn care.

Question: 2 . During the early phase of burn care the nurse

should assess the client for?• 1. Hypernatremia.• 2. Hyponatremia.• 3. Metabolic alkalosis.• 4. Hyperkalemia. - CORRECT ANSWER✔✔11 . 4 . Immediately after a burn, excessive potas sium from cell destruction is released into the extra cellular fluid. Hyponatremia is a common electro lyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of sodium bicarbonate.

Question: 2 . Which of the following clients with burns 2 / 4

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3 will most likely require an endotracheal or tracheostomy tube? A client who has: • 1. Electrical burns of the hands and arms causing arrhythmias.• 2. Thermal burns to the head, face, and airway resulting in hypoxia.• 3. Chemical burns on the chest and abdomen.• 4. Secondhand smoke inhalation. - CORRECT ANSWER✔✔12 . 2 . Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours.Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does

Question: 3 . A client is receiving fluid replacement with

Lactated Ringer's after 40% of his body was burned 3 / 4

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10 hours ago. The assessment reveals: temperature

36.2° C; heart rate 122; blood pressure 84/42; CVP

• mm Hg; and urine output 25 mL for the last 2

hours. The I.V. rate is currently at 375 mL/hour.Using the SBAR (Situation-Background-Assessment Recommendation) technique for communication, the nurse calls the healthcare provider with the

recommendation for:

• 1. Furosemide (Lasix).• 2. Fresh frozen plasma.• 3. I.V. rate increase.• 4. Dextrose 5%. - CORRECT ANSWER✔✔13 . 3 . The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit.Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is Lactated

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