Burns Flashcards
an adult client was burned in an explosion. the burn initially affected the clients entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. the clients clothes caught on fire and the client ran , causing subsequent burn injuries to the posterior torso. using the rule of nines what would be the extent of the burn injury ?
A. 18%
B. 24%
C. 36%
D. 48%
Nclex q 483
C. 36%
the nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. the nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy ?
A. return of distal pulses
B. brisk bleeding from the site
C. decreasing edema formation
D. formation of granulation tissue
Nclex q. 484
A. return of distal pulses
a client is undergoing fluid replacement after being burned on 20% of her body 12 hrs ago. the nursing assessment reveals a blood pressure of 90/50 , a pulse of 110 and a urine output of 20ml over the past hour. the cure reports the findings to the HCP and anticipates for which prescription?
A. transfusing q unit of RBCs
B. administering a diuretic to increase urine output
C. increasing the amount if IV LR solution administered per hour
D. changing the IV LR solution to one the contains 5% dextrose in water
Nclex q.485
C. increasing the amount if IV LR solution administered per hour
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 nurse should implement which nursing actions for this client ?
SATA
A. restrict fluids
B. assess for airway patency
C. administer oxygen as prescribed
D. place a cooling blanket on the client
E. elevate extremities if no fractures are present
F. prepare to give oral pain medication as prescribed
Ncex q.486
B. assess for airway patency
C. administer oxygen as prescribed
E. elevate extremities if no fractures are present
the nurse is caring for a client who sustained superficial partial thickness burns on the anterior lower legs and anterior thorax. which finding does the nurse expect to note during the resuscitation /emergency phase of the burn injury ?
A. decreased heart rate
B. increased urinary output
C. increased blood pressure
D. elevated hematocrit levels
NCLEX q. 487
D. elevated hematocrit levels
the nurse is administering fluids IV as prescribed to a client who sustained superficial partial thickness burn injuries of the back and legs. in evaluating the adequacy of fluid resuscitation the nurse understands that which assessment would provide the most reliable indicator for determining adequacy?
A. vital signs
B. urine output
C. mental status
D. peripheral pulses
NCLEX q. 490
B. urine output
the nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. the nurse manager intervenes if the new nurse planned to implement which unsafe component of protective isolation technique
A. using sterile sheets and linen
B. performing strict hand-washing technique
C. wearing gloves and a gown only when giving direct care to the client
D. wearing protective garb, including a mask, gloves, cap, shoe cover, gowns and plastic apron
NCLEX q.491
C. wearing gloves and a gown only when giving direct care to the client
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 prescribed for the client ?
A. out of bed activities
B. bathroom privileges
C. immobilization of the affected leg
D. placing the affected leg in a dependent position
NCLEX q.492
C. immobilization of the affected leg
a nurse in a providers office is assessing a client who has a severe sunburn. which of the following classifications should the nurse use to document this burn ?
A. superficial thickness
B. superficial partial thickness
C. deep partial thickness
D. full thickness
A. superficial thickness
a nurse is caring for a client who has sustained burns over 35% of total body surface area. the clients voice has become hoarse , brassy cough has developed and the client is drooling. the nurse should identify these findings as indication that the client has which of the following ?
A. pulmonary edema
B. bacterial pneumonia
C. Inhalation Injury
D. carbon monoxide poisoning
C. Inhalation Injury
a nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hr ago. which of the following findings are common during this phase?
SATA
A. Temp of 97
B. bradycardia
C. Hyperkalemia
D. hyponatremia
E. decreased HCT
A. Temp of 97
C. Hyperkalemia
D. hyponatremia
a nurse is preparing to administer fentanyl to a client who sustained deep partial -thickness and full-thickness burns over 60% of the body 24 hr ago. the nurse should plan to use which of the following routes to administer the medication ?
A. SubQ
B. Oral
C. IV
D. Transdermal
C.IV
a nurse is planning care for an adult client who sustained severe burn injuries. which of the following interventions should the nurse include in the plan of care?
SATA
A. Limit visitors in the clients room
B. encourage fresh vegetables in the diet
C. increase protein intake
D. instruct the client to consume 2,000 calorie/day
E. restrict fresh flower in the room
C. increase protein intake
E. restrict fresh flower in the room
the nurse recognizes which etiology as consistent with a thermal burn ?
A. direct current
B. scalding
C. exposure to organic compounds
D. Ionizing radiation
51.1 MSDB
B. scalding
the nurse correlated which clinical manifestation with superficial -parital thickness burns ?
A. Eschar
B. Dry, leathery appearance
C.Blisters
D. waxy appearance
MSDB q. 51.2
C.Blisters
the nurse correlates which zone of burn injury as the most susceptible to sustained injury because of insufficient fluid resuscitation?
A. Zone of stasis
B. Zone of conversion
C. Zone of hyperemia
D. Zone of coagulation
MSDB Q 51.3
A. Zone of stasis
