Saunders NCLEX Review - Burns

Saunders NCLEX Review - Burns ScienceMedicineSurgery KingSport432 Save Saunders Burn Questions 30 terms mikaylamullenvo Preview

Integumentary: Saunders NCLEX Re...

156 terms kaity_gardnerPreview Burns/NCLEX QUESTIONS 20 terms kidniki77Preview Pearso Teacher Kam 509. An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the a subsequent 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 ext 1.18% 2.24% 3.36% 4.48% 3.36% Rationale:Accordingtotheruleofnines,withtheinitialburn,theanteriorhalfoftheheadequals4.5%,theupperhalfoftheanteriortorsoequals9%,andthelowerhal

• The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm

1.Return of distal pulses 2.Brisk bleeding from the site 3.Decreasing edema formation 4.Formation of granulation tissue 1.Return of distal pulses Rationale:Escharotomiesareperformedtorelievethecompartmentsyndromethatcanoccurwhenedemaformsundernondistensibleescharinacircumferentia degreeburn.Escharotomiesareperformedthroughavasculareschartosubcutaneousfat.Althoughbleedingmayoccurfromthesite,itisconsideredacomplicat

• 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

1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains dextrose in water 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Rationale:Fluidmanagementduringthefirst24hoursfollowingaburninjurygenerallyincludestheinfusionof(usually)lactatedRinger'ssolution.Fluidresuscitatio psychological needs.

512.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 Select all that apply.

1.Restrict fluids.

2.Assess for airway patency.

3.Administer oxygen as prescribed.

4.Place a cooling blanket on the client.

5.Elevate extremities if no fractures are present.

6.Prepare to give oral pain medication as prescribed.

2, 3, 5

2.Assess for airway patency.

3.Administer oxygen as prescribed.

5.Elevate extremities if no fractures are present.Rationale:Theprimarygoalforaburninjuryistomaintainapatentairway,administerIVfluidstopreventhypovolemicshock,andpreservevitalorganfunctioning.Th 513.The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does injury?

1.Decreased heart rate 2.Increased urinary output 3.Increased blood pressure 4.Elevated hematocrit levels 4.Elevated hematocrit levels Rationale:Theresuscitation/emergentphasebeginsatthetimeofinjuryandendswiththerestorationofcapillarypermeability,usuallyat48to72hoursfollowingthe 515.A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected.

1.100% oxygen via an aerosol mask 2.Oxygen via nasal cannula at 6L/minute 3.Oxygen via nasal cannula at 15L/minute 4.100% oxygen via a tight-fitting, non rebreather face mask 4.100% oxygen via a tight-fitting, non rebreather face mask

Rationale:Ifaninhalationinjuryissuspected,administrationof100%oxygenviaatight-

fittingnonrebreatherfacemaskisprescribeduntilcarboxyhemoglobinlevelsfall(usuallybelow15%).Ininhalationinjuries,theoropharynxisinspectedforevidenc

516.The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and leg determining the adequacy?

1.Vital signs 2.Urine output 3.Mental status 4.Peripheral pulse 2.Urine output Rationale:Successfuloradequatefluidresuscitationintheclientissignaledbystablevitalsigns,adequateurineoutput,palpableperipheralpulses,andclearsens

• The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new n

isolation technique?

1.Using sterile sheets and linens 2.Performing strict hand washing technique 3.Wearing gloves and a gown only when giving direct care to the client 4.Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron 3.Wearing gloves and a gown only when giving direct care to the client

Rationale:Thoroughhandwashingshouldbedonebeforeandaftereachcontactwiththeburn-

injuredclient.Sterilesheetsandlinensareusedbecauseoftheclient'shighriskforinfection.Protectivegarb,includinggloves,cap,masks,shoecovers,gowns,andp 518.The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be presc 1.Out-of-bed activities 2.Bathroom privileges 3.Immobilization of the affected leg 4.Placing the affected leg in a dependent position 3.Immobilization of the affected leg Rationale:Autograftsplacedoverjointsoronthelowerextremitiesaftersurgeryoftenareelevatedandimmobilizedfor3to7days.Thisperiodofimmobilizationallo Terms (9) Hide definitions