sensory practice questions

Burns NCLEX Leave the first rating Students also studied Terms in this set (12) Save sensory practice questions 24 terms willow444ffPreview Skin Cancer Practice Questions 12 terms ericahandPreview ATI RN Pediatric Nursing Online Pra...60 terms emilymbergers Preview TTP Fin 93 terms Vet The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?

• Superficial partial thickness.
• Deep partial thickness.
• Full thickness.
• First degree.
• Deep partial thickness.

The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?

• A 22-gauge intravenous line with normal saline infusing.
• Wounds covered with moist sterile dressings.
• No intravenous pain medication.
• Ensure adequate peripheral circulation to both

feet.

• Ensure adequate peripheral circulation to both

feet.The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?

• Replace fluids and electrolytes.
• Prevent contractures of extremities.
• Monitor urine output hourly.
• Prepare to assist with an escharotomy.
• Replace fluids and electrolytes.

The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn.Which assessment data would require immediate attention by the nurse?

• The client complains of pain when the medication is

administered.

• The client's potassium level is 3.9 mEq/L and sodium

level is 137 mEq/L.

• The client's ABGs are pH 7.34, Pao2 98, Paco2 38, and

HCO3 20.

• The client is able to perform active range-of- motion

exercises.

• The client's ABGs are pH 7.34, Pao2 98, Paco2 38, and HCO3 20.

The client is scheduled to have a xenograft toa left lower- leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response?

• "The doctor will graft skin from your back to your leg."
• "The skin from a donor will be used to cover your

burn."

• "The graft will come from an animal, probably a pig."
• "I think you should ask your doctor about the graft."
• "The graft will come from an animal, probably a pig."

The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body.Which client problem has priority?

• High risk for infection.
• Ineffective coping.
• Impaired physical mobility.
• Knowledge deficit.
• High risk for infection.

The nurse writes the nursing diagnosis "impaired skin integrity related to openburn wounds." Which intervention would be appropriate for this nursing diagnosis?1. Provide analgesia before pain becomes severe.

• Clean the client's wounds, body, and hair daily.
• Screen visitors for respiratory infections.
• Encourage visitors to bring plants and flowers.
• Clean the client's wounds, body, and hair daily.

Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply.

• Perform meticulous hand hygiene.
• Use sterile gloves for wound care.
• Wear gown and mask during procedures.
• Change central lines once a week.
• Administer antibiotics as prescribed.
• Perform meticulous hand hygiene.
• Use sterile gloves for wound care.
• Wear gown and mask during procedures.
• Administer antibiotics as prescribed.

The nurse is caring for a client with deep partial- thickness and full-thickness burns to the chest area.Which assessment data would warrant notifying the health-care provider?

• The client is complaining of severe pain.
• The client's pulse oximeter reading is 95%.
• The client has T 100.4oF, P 100, R 24, and BP 102/60.
• The client's urinary output is 50 mL in two (2) hours.
• The client's urinary output is 50 mL in two (2) hours.

The client is admitted with full-thickness and partial- thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement?

• Encourage the client's family to bring favorite foods.
• Provide a low-fat, low-cholesterol diet for the client.
• Monitor the client's weight weekly in the same clothes.
• Make a referral to the hospital social worker.
• Encourage the client's family to bring favorite foods.

The client sustained a hot grease burn to the right hand and calls the emergency department for advice. Which information should the nurse provide to the client?

• Apply an ice pack to the right hand.
• Place the hand in cool water.
• Be sure to rupture any blister formation.
• Go immediately to the doctor's office.
• Place the hand in cool water.

The client is being discharged after being inthe burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health?

• Encourage the client to stay at home as much as

possible.

• Discuss the importance of not relying on the family for

needs.

• Tell the client to remember that changes in lifestyle

take time.

• Instruct the client to discuss feelings only with the

therapist.

• Tell the client to remember that changes in lifestyle take time.