TEST 1 BURNS

Question 1

1. Burns diet (pg.917)

Answer 1

 increase calories & protein
 increase fluid intake
 increase vitamin A (fatty fish, egg yolks, dark yellow/orange fruits
& veggies: yam, carrots, apricots, squash, cantoloupe)
 increase vitamin C (oranges, orange juice, strawberries, green leafy veggies, tomatoes, lemons, peppers)
 increase vitamin zinc (meat, fish, seafood, oysters, lentils, Greek yogurt, broccoli, kidney beans, blueberries)

Question 2

1. Burns nursing actions

Answer 2

 Use a cradle sheet to maintain body warmth
 Assess for patent airway or evidence of inhalation injury, monitor respiratory
 Avoid using sponges for baths
 Change gloves between different areas of burns
 Evaluate pain & administer IV analgesics

Question 3

1. Burns priority care

Answer 3

 Give IV fluid (crystalloid & colloid)
 Give IV analgesics
 Give O2 as ordered
 Restrict oral meds & fluids
 Elevate extremities above heart level to prevent shock
 Use powder free sterile gloves
 Client may have slight hoarseness, if it gets worse this indicates respiratory distress or if nose hairs have black soot beware it can also sign of respiratory distress due to inhalation injury

Question 4

2. Skin grafting client education

Answer 4

 Use of sunscreen w/high sun protection factor when outdoors
 Use pressure garment after healing
 Use mild soap, wash & rinse thoroughly, patted dry.
 Avoid things w/irritants(lanolin, alcohol, perfumes)
 Wear warm clothing w/skin graft
 Film dressing to cover at first

Question 5

2. Skin grafting nursing actions (pg.915)

Answer 5

 Administer pain analgesics
 Monitor for infections
 1st 2-4weeks restrict movement

Question 6

3. Hypovolemic shock evaluation outcomes

Answer 6

-urinary output w/in normal limits
-normal V/S

Question 7

3. Hypovolemic shock medical management (ATI pg.234)

Answer 7

 Fluid replacement w/colloids & crystalloids- LR & NS (mainly as first line) Ratio of 3:1 fluids

 Vasoconstrictors (dopamine, norepinephrine, phenylephrine)

Question 8

3. Hypovolemic shock nursing actions (pp slide 3)

Answer 8

 Prepare for administration of blood & fluids (NS & or LR w/3:1 ratio)

 O2 administration (on forehead for o2 stat)

 Monitor weight, VS, including temperature (risk of hypothermia w/large volumes of fluid)

 Position client supine or Trendelenburg w/feet slightly elevated. Never high fowlers. (adjust for respiratory s/s)

Question 9

4. Septic shock early manifestations (initial phase) pp slide 6

Answer 9

 Elevated WBC
 Fever
 Warm, flushed skin —>Progresses to cold pale skin
 Rapid, bounding pulse

Later manifestations:
 Hypotensive
 Delayed capillary refill
 Disorientation

Question 10

5. Impending Shock: nursing actions (pp slide 13)

Answer 10

Decreased cardiac output impending shock
 Restrict activity to total rest
 Establish IV sites
 Assist w/fluids/bloods

IMPAIRED TISSUE PERFUSION
 Assess w/Neurovascular checks
 Control frank bleeding
 Elevate legs

Question 11

6. Hemorrhagic shock: medical management

Answer 11

 Fluid replacement w/colloids & crystalloids
 Vasoconstrictors (dopamine, norepinephrine, phenylephrine)
 Transfuse O- blood to client who is bleeding profusely

Question 12

7. Neurogenic shock manifestations (pp slide 7):

Answer 12

 Dry, warm skin
 Hypotension
 Bradycardia

Question 13

8. Stages of shock: manifestations (pp slide 9)

Answer 13

Initial:
 Too little O2 in blood to feed organs-anaerobic metabolism (mostly absent s/s)

Compensatory:
 Increased HR
 RR increases
 BP can be stable

Progressive:
 Cold & clammy skin
 Early sign: body cant compensate

Irreversible:
 multi
 Multi-organ failure & death

Question 14

9. Hypovolemic & Cardiogenic Shock causes?

Answer 14

 Blood or plasma loss, surgery, trauma, birth
 Fluid loss, burns, large draining wounds, suctioning, diabetes insipidus

Cardiogenic shock causes:
MI,HF

Question 15

9. Septic shock causes

Answer 15

 Bacterial infections (E-coli, Staphylococcus aureus, psuedomonas)
 Endotoxins: harmful chemicals

Question 16

9. Neurogenic Shock causes:

Answer 16

 General anesthetic
 Opioid overdose
 Tranquilizers
 Spinal cord injury T6 or higher

Question 17

9. Anaphylactic shock causes

Answer 17

 Bee venom
 Latex
 Fish
 Nuts
 PCN (penicillin)

Question 18

9. Obstructive shock causes:

Answer 18

 Cardiac tamponade
 Ascites or enlarged liver
 Tension Pneumothorax

Question 19

10. Primary shock assessment (pp slide 10)

Answer 19

 Compromised blood volume or circulation
 VS
 Peripheral pulses
 Changes in mentation
 Skin
 Urine output
 Bowel sounds

Question 20

10. Continued shock assessment (pp slide 12)

Answer 20

 Respirations: shallow, grunting, air hungry, rate decreases as stages progresss
 Temp: increase heat loss, subnormal
 Mentation: altered cerebral function often first sigh of early stage
-anxiety
-restlessness
-agitation
-confusion, progresses to loss of consciousness
 Skin: cold/clammy, pale, mottled, increased cap refill, cyanosis as stages progress
 Urine output: oliguria, renal damage