Quiz 6 Flashcards
A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small,
the burn must not be too bad. Which of the following is the best response by the nurse?
Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
Which of the following actions should the nurse take when caring for a client with severe burns? Select all that
apply.
opiate analgesics
benzodiazepines
A nurse is caring for a client during fluid resuscitation for burns. Which of the following are used to evaluate the
success of fluid resuscitation? (Select all that apply.)
Blood pressure
Level of consciousness
Urine output
A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? Select all that apply.
Loss of protein
Capillary leak
Decreased plasma volume
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the
head, neck, and chest. While planning the client’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?
Airway obstruction: When using the airway, breathing, circulation approach to client care, the nurse determines that
the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client’s care.
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client
has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if
it applies. Do not use a trailing zero.)
31.5 %
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Inspect the mouth for signs of inhalation injuries.: Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client’s burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing,
circulation (ABC) priority-setting framework, is the priority concern at this time.
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?
Monitor the pulmonary artery pressure: Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. The pulmonary artery pressure provides an accurate assessment of the
cardiovascular system by detecting changes in both right and left heart pressure which can indicate possible development of pulmonary edema, as well monitor overall fluid status.
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse’s priority when assessing the severity of the client’s burns?
Location of the burn: When using the urgent vs. nonurgent approach to client care, the nurse determines the priority
is to assess the location of the burns that can lead to respiratory distress.
A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and
arms. Using the rule of nines the nurse should document burns to which percentage of the client’s total body
surface area (TBSA)?
54 percent: Each arm represents 9% of the client’s TBSA and each leg represents 18% of the client’s TBSA
totaling 54%.
A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities.
Which of the following interventions should the nurse perform first?
Administer IV fluids.: Using the airway, breathing, circulation framework, the priority action the nurse should take is
to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids.
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the
following is the priority finding to report to the provider?
Difficulty swallowing: Using the airway, breathing, circulation approach to client care, the nurse should determine
that the priority finding is difficulty swallowing as this is can be an indication that the client’s airway is obstructed.
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his
chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation of
phase of injury?
Maintain the airway.
A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?
The burned area is red in color with eschar present.: This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain. At this stage, the eschar that is present is soft and dry.
A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic
hormone (SIADH). Which of the following manifestations should the nurse anticipate?
Oliguria: The nurse should expect a client who has developed SIADH following a craniotomy to manifest oliguria. The decrease in urine output can be dramatic with output less than 20
mL/hr.
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level
of 123 mEq/L. Which of the following prescriptions should the nurse anticipate?
Restrict fluid intake to 1,000 mL per day.: Clients who have SIADH have an increased amount of antidiuretic hormone, which results in excess fluid volume. This excess fluid dilutes the sodium level in the blood, causing dilutional hyponatremia. Oral fluids are restricted in an attempt to restore the fluid balance and the sodium level in the blood. The nurse should offer this client frequent oral care to prevent discomfort and breakdown of the oral mucosa.
A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that
which the following laboratory findings indicate a therapeutic effect of the medication?
Urine specific gravity 1.015: A therapeutic effect of the medication would be urine specific gravity within the expected
reference range, which is 1.010-1.025.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings is a manifestation of this
diagnosis?
Tachycardia: Tachycardia is a manifestation of diabetes insipidus due to dehydration from fluid loss.
A nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse, “I feel so isolated and alone in this room.” After acknowledging the client’s feelings of loneliness, which of the following responses should the nurse provide?
“Do you have a cell phone you can talk to friends and family on?”: A client who has a radiation implant must remain in radiation isolation. Time and distance are
the factors that reduce exposure to the source. After acknowledging the client’s feelings of loneliness and recognizing the sense of social isolation, this solution provides an appropriate, safe means of meeting the client’s need for contact.
A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be
dysphagia: Radiation therapy does not hurt while it is being given. But the side effects that people may
get from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin
redness.
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor
the client for which of the following adverse effects?
Bleeding from the gums: Bleeding from the gums is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets.
A female middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations?
Developing breast cancer: The BRCA1 gene is used to determine the probability of a client developing breast cancer.
BRCA1 genetic testing is used for women who have a strong family history of breast cancer.
