Chapter 24 Burns - test bank PDF

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TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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Chapter24:Burns TestBank MULTIPLECHOICE 1.Whenassessingapatientwhospilledhotoilontherightlegandfoot,thenursenotesthattheskinisdry, pale,hardskin.Thepatientstatesthattheburnisnotpainful.Whattermwouldthenurseusetodocumentthe burndepth? a.

First-degreeskindestruction

b.

Full-thicknessskindestruction

c.

Deeppartial-thicknessskindestruction

d.

Superficialpartial-thicknessskindestruction

ANS:B Withfull-thicknessskindestruction,theappearanceispaleanddryorleatheryandtheareaispainlessbecause oftheassociatednervedestruction.Erythema,swelling,andblisterspointtoadeeppartial-thicknessburn. Withsuperficialpartial-thicknessburns,theareaisred,butnoblistersarepresent.First-degreeburnsexhibit erythema,blanching,andpain. DIF:CognitiveLevel:Understand(comprehension)REF:433 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 2.Onadmissiontotheburnunit,apatientwithanapproximate25%totalbodysurfacearea(TBSA)burnhas thefollowinginitiallaboratoryresults:Hct58%,Hgb18.2mg/dL(172g/L),serumK+4.9mEq/L(4.8 mmol/L),andserumNa+135mEq/L(135mmol/L).Whichactionwillthenurseanticipatetakingnow? a.

Monitorurineoutputevery4hours.

b.

Continuetomonitorthelaboratoryresults.

c.

IncreasetherateoftheorderedIVsolution.

d.

Typeandcrossmatchforabloodtransfusion.

ANS:C Thepatientslaboratorydatashowhemoconcentration,whichmayleadtoadecreaseinbloodflowtothe microcirculationunlessfluidintakeisincreased.Becausethehematocritandhemoglobinareelevated,a transfusionisinappropriate,althoughtransfusionsmaybeneededaftertheemergentphaseoncethepatients fluidbalancehasbeenrestored.Onadmissiontoaburnunit,theurineoutputwouldbemonitoredmoreoften thanevery4hours;likelyevery1hour. DIF:CognitiveLevel:Apply(application)REF:244

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TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 3.Apatientisadmittedtotheburnunitwithburnstothehead,face,andhands.Initially,wheezesareheard, butanhourlater,thelungsoundsaredecreasedandnowheezesareaudible.Whatisthebestactionforthe nursetotake? a.

Encouragethepatienttocoughandauscultatethelungsagain.

b.

Notifythehealthcareproviderandprepareforendotrachealintubation.

c.

Documenttheresultsandcontinuetomonitorthepatientsrespiratoryrate.

d.

Repositionthepatientinhigh-Fowlerspositionandreassessbreathsounds.

ANS:B Thepatientshistoryandclinicalmanifestationssuggestairwayedemaandthehealthcareprovidershouldbe notifiedimmediately,sothatintubationcanbedonerapidly.Placingthepatientinamoreuprightpositionor havingthepatientcoughwillnotaddresstheproblemofairwayedema.Continuingtomonitorisinappropriate becauseimmediateactionshouldoccur. DIF:CognitiveLevel:Apply(application)REF:438 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 4.ApatientwithsevereburnshascrystalloidfluidreplacementorderedusingtheParklandformula.Theinitial volumeoffluidtobeadministeredinthefirst24hoursis30,000mL.Theinitialrateofadministrationis1875 mL/hr.Afterthefirst8hours,whatrateshouldthenurseinfusetheIVfluids? a.

350mL/hour

b.

523mL/hour

c.

938mL/hour

d.

1250mL/hour

ANS:C HalfofthefluidreplacementusingtheParklandformulaisadministeredinthefirst8hoursandtheotherhalf overthenext16hours.Inthiscase,thepatientshouldreceivehalfoftheinitialrate,or938mL/hr. DIF:CognitiveLevel:Apply(application)REF:439 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 5.Duringtheemergentphaseofburncare,whichassessmentwillbemostusefulindeterminingwhetherthe patientisreceivingadequatefluidinfusion? a.

Checkskinturgor.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

b.

Monitordailyweight.

c.

Assessmucousmembranes.

d.

Measurehourlyurineoutput.

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ANS:D Whenfluidintakeisadequate,theurineoutputwillbeatleast0.5to1mL/kg/hour.Thepatientsweightisnot usefulinthissituationbecauseoftheeffectsofthirdspacingandevaporativefluidloss.Mucousmembrane assessmentandskinturgoralsomaybeused,buttheyarenotasadequateindeterminingthatfluidinfusions aremaintainingadequateperfusion. DIF:CognitiveLevel:Apply(application)REF:439 TOP:NursingProcess:EvaluationMSC:NCLEX:PhysiologicalIntegrity 6.Apatienthasjustbeenadmittedwitha40%totalbodysurfacearea(TBSA)burninjury.Tomaintain adequatenutrition,thenurseshouldplantotakewhichaction? a.

Insertafeedingtubeandinitiateenteralfeedings.

b.

Infusetotalparenteralnutritionviaacentralcatheter.

c.

Encourageanoralintakeofatleast5000kcalperday.

d.

AdministermultiplevitaminsandmineralsintheIVsolution.

ANS:A Enteralfeedingscanusuallybeinitiatedduringtheemergentphaseatlowratesandincreasedover24to48 hourstothegoalrate.Duringtheemergentphase,thepatientwillbeunabletoeatenoughcaloriestomeet nutritionalneedsandmayhaveaparalyticileusthatpreventsadequatenutrientabsorption.Vitaminsand mineralsmaybeadministeredduringtheemergentphase,butthesewillnotassistinmeetingthepatients caloricneeds.Parenteralnutritionincreasestheinfectionrisk,doesnothelppreservegastrointestinalfunction, andisnotroutinelyusedinburnpatients. DIF:CognitiveLevel:Apply(application)REF:442 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 7.Whilethepatientsfullthicknessburnwoundstothefaceareexposed,whatisthebestnursingactionto preventcrosscontamination? a.

Usesterilegloveswhenremovingolddressings.

b.

Weargowns,caps,masks,andglovesduringallcareofthepatient.

c.

AdministerIVantibioticstopreventbacterialcolonizationofwounds.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

d.

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Turntheroomtemperatureuptoatleast70F(20C)duringdressingchanges.

ANS:B Useofgowns,caps,masks,andglovesduringallpatientcarewilldecreasethepossibilityofwound contaminationforapatientwhoseburnsarenotcovered.Whenremovingcontaminateddressingsandwashing thedirtywound,usenonsterile,disposablegloves.Theroomtemperatureshouldbekeptatapproximately85F forpatientswithopenburnwoundstopreventshivering.Systemicantibioticsarenotwellabsorbedintodeep burnsbecauseofthelackofcirculation. DIF:CognitiveLevel:Apply(application)REF:440 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 8.Anurseiscaringforapatientwhohasburnsoftheears,head,neck,andrightarmandhand.Thenurse shouldplacethepatientinwhichposition? a.

Placetherightarmandhandflexedinapositionofcomfort.

b.

Elevatetherightarmandhandonpillowsandextendthefingers.

c.

Assistthepatienttoasupinepositionwithasmallpillowunderthehead.

d.

Positionthepatientinaside-lyingpositionwithrolledtowelundertheneck.

ANS:B Therighthandandarmshouldbeelevatedtoreduceswellingandthefingersextendedtoavoidflexion contractures(eventhoughthispositionmaynotbecomfortableforthepatient).Thepatientwithburnsofthe earsshouldnotuseapillowfortheheadbecausethiswillputpressureontheears,andthepillowmaystickto theears.Patientswithneckburnsshouldnotuseapillowbecausetheheadshouldbemaintainedinan extendedpositioninordertoavoidcontractures. DIF:CognitiveLevel:Apply(application)REF:441 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 9.Apatientwithcircumferentialburnsofbothlegsdevelopsadecreaseindorsalispedispulsestrengthand numbnessinthetoes.Whichactionshouldthenursetake? a.

Notifythehealthcareprovider.

b.

Monitorthepulsesevery2hours.

c.

Elevatebothlegsaboveheartlevelwithpillows.

d.

Encouragethepatienttoflexandextendthetoesonbothfeet.

ANS:A Thedecreaseinpulseinapatientwithcircumferentialburnsindicatesdecreasedcirculationtothelegsandthe

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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needforanescharotomy.Monitoringthepulsesisnotanadequateresponsetothedecreaseincirculation. Elevatingthelegsorincreasingtoemovementwillnotimprovethepatientscirculation. DIF:CognitiveLevel:Apply(application)REF:437 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 10.Esomeprazole(Nexium)isprescribedforapatientwhoincurredextensiveburninjuries5daysago.Which nursingassessmentwouldbestevaluatetheeffectivenessofthemedication? a.

Bowelsounds

b.

Stoolfrequency

c.

Abdominaldistention

d.

Stoolsforoccultblood

ANS:D H2blockersandprotonpumpinhibitorsaregiventopreventCurlingsulcerinthepatientwhohassuffered burninjuries.Protonpumpinhibitorsusuallydonotaffectbowelsounds,stoolfrequency,orappetite. DIF:CognitiveLevel:Apply(application)REF:444 TOP:NursingProcess:EvaluationMSC:NCLEX:PhysiologicalIntegrity 11.Thenurseisreviewingthemedicationadministrationrecord(MAR)onapatientwithpartial-thickness burns.Whichmedicationisbestforthenursetoadministerbeforescheduledwounddebridement? a.

Ketorolac(Toradol)

b.

Lorazepam(Ativan)

c.

Gabapentin(Neurontin)

d.

Hydromorphone(Dilaudid)

ANS:D Opioidpainmedicationsarethebestchoiceforpaincontrol.Theothermedicationsareusedasadjuvantsto enhancetheeffectsofopioids. DIF:CognitiveLevel:Apply(application)REF:446 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 12.Ayoungadultpatientwhoisintherehabilitationphaseafterhavingdeeppartial-thicknessfaceandneck burnshasanursingdiagnosisofdisturbedbodyimage.Whichstatementbythepatientindicatesthatthe problemisresolving? a.

Imgladthescarsareonlytemporary.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

b.

Iwillavoidusingapillow,somyneckwillbeOK.

c.

Ibetmyboyfriendwontevenwanttolookatmeanymore.

d.

Doyouthinkdarkbeigemakeupfoundationwouldcoverthisscaronmycheek?

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ANS:D Thewillingnesstousestrategiestoenhanceappearanceisanindicationthatthedisturbedbodyimageis resolving.Expressingfeelingsaboutthescarsindicatesawillingnesstodiscussappearance,butnotresolution oftheproblem.Becausedeeppartial-thicknessburnsleavepermanentscars,astatementthatthescarsare temporaryindicatesdenialratherthanresolutionoftheproblem.Avoidingusingapillowwillhelpprevent contractures,butitdoesnotaddresstheproblemofdisturbedbodyimage. DIF:CognitiveLevel:Apply(application)REF:448 TOP:NursingProcess:EvaluationMSC:NCLEX:PsychosocialIntegrity 13.Thenursecaringforapatientadmittedwithburnsover30%ofthebodysurfaceassessesthaturineoutput hasdramaticallyincreased.Whichactionbythenursewouldbestensureadequatekidneyfunction? a.

Continuetomonitortheurineoutput.

b.

Monitorforincreasedwhitebloodcells(WBCs).

c.

Assessthatblistersandedemahavesubsided.

d.

Preparethepatientfordischargefromtheburnunit.

ANS:A Thepatientsurineoutputindicatesthatthepatientisenteringtheacutephaseoftheburninjuryandmovingon fromtheemergentstage.Attheendoftheemergentphase,capillarypermeabilitynormalizesandthepatient beginstodiureselargeamountsofurinewithalowspecificgravity.Althoughthismayoccuratabout48 hours,itmaybelongerinsomepatients.Blistersandedemabegintoresolve,butthisprocessrequiresmore time.Whitebloodcellsmayincreaseordecrease,basedonthepatientsimmunestatusandanyinfectious processes.TheWBCcountdoesnotindicatekidneyfunction.Thepatientwilllikelyremainintheburnunit duringtheacutestageofburninjury. DIF:CognitiveLevel:Understand(comprehension)REF:443 TOP:NursingProcess:ApplicationMSC:NCLEX:PhysiologicalIntegrity 14.Apatientwithburnscovering40%totalbodysurfacearea(TBSA)isintheacutephaseofburntreatment. Whichsnackwouldbebestforthenursetooffertothispatient? a.

Bananas

b.

Orangegelatin

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

c.

Vanillamilkshake

d.

Wholegrainbagel

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ANS:C Apatientwithaburninjuryneedshighproteinandcaloriefoodintake,andthemilkshakeisthehighestin thesenutrients.Theotherchoicesarenotasnutrient-denseasthemilkshake.Gelatinislikelyhighinsugar. Thebagelisagoodcarbohydratechoice,butlowinprotein.Bananasareagoodsourceofpotassium,butare nothighinproteinandcalories. DIF:CognitiveLevel:Apply(application)REF:446 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 15.Apatienthasjustarrivedintheemergencydepartmentafteranelectricalburnfromexposuretoahighvoltagecurrent.Whatistheprioritynursingassessment? a.

Oraltemperature

b.

Peripheralpulses

c.

Extremitymovement

d.

Pupilreactiontolight

ANS:C Allpatientswithelectricalburnsshouldbeconsideredatriskforcervicalspineinjury,andassessmentsof extremitymovementwillprovidebaselinedata.Theotherassessmentdataarealsonecessarybutnotas essentialasdeterminingthecervicalspinestatus. DIF:CognitiveLevel:Apply(application)REF:431 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Assessment MSC:NCLEX:PhysiologicalIntegrity 16.Anemployeespillsindustrialacidsonbotharmsandlegsatwork.Whatisthepriorityactionthatthe occupationalhealthnurseatthefacilityshouldtake? a.

Removenonadherentclothingandwatch.

b.

Applyanalkalinesolutiontotheaffectedarea.

c.

Placecoolcompressesontheareaofexposure.

d.

Covertheaffectedareawithdry,steriledressings.

ANS:A

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Withchemicalburns,theinitialactionistoremovethechemicalfromcontactwiththeskinasquicklyas possible.Removenonadherentclothing,shoes,watches,jewelry,glasses,orcontactlenses(iffacewas exposed).Flushchemicalfromwoundandsurroundingareawithcopiousamountsofsalinesolutionorwater. Coveringtheaffectedareaorplacingcoolcompressesontheareawillleavethechemicalincontactwiththe skin.Applicationofanalkalinesolutionisnotrecommended. DIF:CognitiveLevel:Apply(application)REF:434 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 17.Apatientwhohasburnsonthearms,legs,andchestfromahousefirehasbecomeagitatedandrestless8 hoursafterbeingadmittedtothehospital.Whichactionshouldthenursetakefirst? a.

Stayatthebedsideandreassurethepatient.

b.

AdministertheorderedmorphinesulfateIV.

c.

Assessorientationandlevelofconsciousness.

d.

Usepulseoximetrytochecktheoxygensaturation.

ANS:D Agitationinapatientwhomayhavesufferedinhalationinjurymightindicatehypoxia,andthisshouldbe assessedbythenursefirst.Administrationofmorphinemaybeindicatedifthenursedeterminesthatthe agitationiscausedbypain.Assessinglevelofconsciousnessandorientationisalsoappropriatebutnotas essentialasdeterminingwhetherthepatientishypoxemic.Reassuranceisnothelpfultoreduceagitationina hypoxemicpatient. DIF:CognitiveLevel:Apply(application)REF:437 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 18.Apatientarrivesintheemergencydepartmentwithfacialandchestburnscausedbyahousefire.Which actionshouldthenursetakefirst? a.

Auscultatethepatientslungsounds.

b.

Determinetheextentanddepthoftheburns.

c.

InfusetheorderedlactatedRingerssolution.

d.

Administertheorderedhydromorphone(Dilaudid).

ANS:A Apatientwithfacialandchestburnsisatriskforinhalationinjury,andassessmentofairwayandbreathingis thepriority.Theotheractionswillbecompletedafterairwaymanagementisassured.

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DIF:CognitiveLevel:Apply(application)REF:431 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 19.Apatientwithextensiveelectricalburninjuriesisadmittedtotheemergencydepartment.Whichprescribed interventionshouldthenurseimplementfirst? a.

Assessoraltemperature.

b.

Checkapotassiumlevel.

c.

Placeoncardiacmonitor.

d.

Assessforpainatcontactpoints.

ANS:C Afteranelectricalburn,thepatientisatriskforfataldysrhythmiasandshouldbeplacedonacardiacmonitor. Assessingtheoraltemperatureisnotasimportantasassessingforcardiacdysrhythmias.Checkingthe potassiumlevelisimportant.However,itwilltaketimebeforethelaboratoryresultsareback.Thefirst interventionistoplacethepatientonacardiacmonitorandassessfordysrhythmias,sothattheycanbetreated ifoccurring.Adecreasedorincreasedpotassiumlevelwillalertthenursetothepossibilityofdysrhythmias. Thecardiacmonitorwillalertthenurseimmediatelyofanydysrhythmias.Assessingforpainisimportant,but thepatientcanendurepainuntilthecardiacmonitorisattached.Cardiacdysrhythmiascanbelethal. DIF:CognitiveLevel:Analyze(analysis)REF:431 OBJ:SpecialQuestions:PrioritizationTOP...