Chapter 46--Burns: Nursing Management

Chapter 46--Burns: Nursing Management MULTIPLE CHOICE 1. The nurse is assessing a client’s burn for the zones of injury. Which of the following will the nurse not assess in the client at this time? 1. Zone of co ...

Chapter 46--Burns: Nursing Management MULTIPLE CHOICE 1. The nurse is assessing a client’s burn for the zones of injury. Which of the following will the nurse not assess in the client at this time? 1. Zone of coagulation 2. Zone of eschar 3. Zone of hyperemia 4. Zone of stasis PTS: 1 DIF: Analyze REF: Local Tissue Response 2. Which of the following will the nurse most likely assess in a client diagnosed with a second-degree burn? 1. No pain and necrotic areas 2. No pain and scarring 3. Pain and blisters 4. Pain and peeling after 2 to 5 days PTS: 1 DIF: Apply REF: Pathophysiology 3. The nurse, caring for a client with severe burns, realizes that the client’s care will progress through specific periods of treatment EXCEPT: 1. acute period. 2. emergent period. 3. rehabilitation period. 4. stabilization period. PTS: 1 DIF: Analyze REF: Planning and Implementation 4. A client who has experienced a burn is in the emergent phase of treatment that usually occurs during which of the following periods? 1. 24 to 48 hours 2. 36 to 72 hours 3. 48 to 96 hours 4. 1 to 7 days PTS: 1 DIF: Analyze REF: Planning and Implementation 5. A client is beginning the initial treatment of a major burn in the emergency room. Which of the following interventions would not be completed? 1. Inserting an indwelling urinary catheter 2. Intubatng the patient 3. Giving oral medications for pain management 4. Starting an intravenous solution of Ringer’s lactate PTS: 1 DIF: Apply REF: Emergency Department Management 6. The formula used to calculate the volume of intravenous (IV) fluid required for fluid resuscitation of a client receiving care in the first 24 hours after a burn is: 1. 1 to 2 mL of lactated Ringer’s solution  body weight  percent burn. 2. 2 to 3 mL of lactated Ringer’s solution  body weight  percent burn. 3. 2 to 4 mL of lactated Ringer’s solution  body weight  percent burn. 4. 3 to 6 mL of lactated Ringer’s solution  body weight  percent burn. PTS: 1 DIF: Apply REF: Planning and Implementation 7. A client is being evaluated in the emergency department following a burn injury at home. The client has second- and third-degree burns to the right and left arms, back, and both posterior legs. Using the rule of nines, the nurse would calculate this client’s burn as being: 1. 36%. 2. 45%. 3. 54%. 4. 63%. PTS: 1 DIF: Apply REF: Figure 46-3 Rule of Nines 8. Health care professionals are required to report suspected abuse or neglect. Which of the following is not a typical sign of abuse with a burn injury? 1. Emergency management notification of a burn injury within 1 hour of occurrence 2. A burn injury accompanied by fracture and bruises 3. Differing accounts of how the injury occurred with each new interview 4. Treatment sought by a non-relation PTS: 1 DIF: Analyze REF: Law in Practice: Burns as a Result of Abuse 9. The nurse is assessing a client diagnosed with second- and third-degree burns. Which of the following assessment signs would not need to be reported by the nurse? 1. Brassy cough 2. Hoarseness 3. Respiratory rate of 36 4. Urine output of 30 mL in the first hour PTS: 1 DIF: Apply REF: Planning and Implementation 10. A nurse is managing the fluid status of a client being treated for a burn. Which of following is an indicator of adequate fluid resuscitation? 1. Blood pressure 95/60 mmHg 2. Pulse 115 bpm 3. Patient confusion 4. Urine output 30 mL/hr PTS: 1 DIF: Analyze REF: Planning and Implementation 11. The nurse is initiating care for a client diagnosed with burns to the chest, back, neck, and face. For this client, which of the following nursing diagnoses would receive the highest priority? 1. Disturbed body image 2. Impaired skin integrity 3. Ineffective airway clearance 4. Risk for infection PTS: 1 DIF: Apply REF: Planning and Implementation 12. A client is scheduled to receive a skin graft from another species as part of the treatment for a burn wound. Which of the following is a graft of skin obtained from another species? 1. Allograft 2. Autograft 3. Heterograft 4. Homograft PTS: 1 DIF: Analyze REF: Acute Phase: Surgery 13. A client is recovering from a skin graft to her right arm. Which of the following nursing interventions would not be indicated for this client? 1. Assess for bleeding. 2. Assess for drainage underneath the graft site. 3. Encourage exercise of the right arm. 4. Remove dressings slowly. PTS: 1 DIF: Apply REF: Acute Phase: Surgery 14. A client diagnosed with a major burn is being prescribed medication for pain. The nurse realizes that the drug of choice for this client will be: 1. morphine sulfate. 2. acetaminophen. 3. aspirin. 4. meperidine. PTS: 1 DIF: Analyze REF: Pharmacology 15. To support the nutritional needs of a client recovering from a burn injury, the nurse will prepare to administer which of the following? 1. High carbohydrate diet 2. High fat diet 3. Low protein diet 4. Vitamins C and A supplements PTS: 1 DIF: Apply REF: Nutrition MULTIPLE RESPONSE 1. A client has been diagnosed with a full-thickness burn injury to the hands and arms. Which of the following characteristics would the nurse expect to find? (Select all that apply.) 1. Blanches with fingertip pressure 2. Charred vessels visible under eschar 3. Many blisters that increase in size 4. Nerve endings dead 5. No edema 6. Very painful PTS: 1 DIF: Analyze REF: Pathophysiology 2. The goals of management during the emergent period after a burn include which of the following? (Select all that apply.) 1. Airway management 2. Aseptic technique 3. Emotional support 4. Fluid replacement 5. Pain management 6. Rehabilitation PTS: 1 DIF: Apply REF: Emergent Phase 3. An individual’s sleeve catches on fire while cooking. He runs through the kitchen and out the back door. Which of the following interventions should the family perform? (Select all that apply.) 1. Have the individual stand for easy access. 2. Remove any loose debris. 3. Remove clothing adhered to the burned area. 4. Remove jewelry. 5. Use the water hose to cool the burn. 6. Cover the burned areas with a clean dry material. PTS: 1 DIF: Apply REF: Prehospital Care and First Aid 4. The nurse is determining if a client who sustained a burn should be referred to a burn unit for care. Which of the following types of burn injuries should be referred to this type of care area? (Select all that apply.) 1. Burn on the face 2. Burn to the genitalia 3. Burn to a fractured limb 4. Sunburn 5. Burn caused by hot water to approximately 5 inches of the forearm 6. Burn caused by chemicals PTS: 1 DIF: Analyze REF: Box 46-2 Burn Center Referral Criteria 5. The nurse is preparing to provide wound care to a client newly diagnosed with a burn. Which of the following are goals of this initial wound care? (Select all that apply.) 1. Hydrate the skin. 2. Cleanse the skin. 3. Prevent further skin destruction. 4. Provide comfort. 5. Prevent nutritional deficits. 6. Prevent infection. PTS: 1 DIF: Apply REF: Planning and Implementation