Summary-RNSG 2930 spring final 2022/2023
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nur...
summary rnsg 2930 spring final 20222023 the client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs the assessment rev
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Summary-RNSG 2930 spring final
2022/2023
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water
accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both
feet are edematous. Which depth of burn should the nurse document?
1. Superficial partial thickness.
2. Deep partial thickness.
3. Full thickness.
4. First degree
1. Sunburn is an example of this depth of burn; a superficial partial-thickness burn affects the epidermis
and the skin is reddened and blanches with pressure.
***2. Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis,
and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema.
3. Full-thickness burns are caused by flame, electric current, or chemical burns and include the
epidermis, entire dermis, and sometimes subcutaneous tissue and may also involve connective tissue,
muscle, and bone. 4. First-degree burn is another name for a superficial partial-thickness burn.
TEST-TAKING HINT: The adjectives in the stem are the most important words that assist the test taker
when selecting a correct answer
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a
community hospital to a burn center. Which measure should be instituted before the transfer?
1. A 22-gauge intravenous line with normal saline infusing.
2. Wounds covered with moist sterile dressings.
3. No intravenous pain medication.
4. Adequate peripheral circulation to both feet ensured.
1. An 18-gauge catheter with lactated Ringer's infusion should be initiated to maintain a urine output of
at least 30 mL/hr.
2. Wounds should be covered with a clean, dry sheet.
3. The client should be transferred with adequate pain relief, which requires intravenous morphine.
***4. The client's legs should have pedal pulses and be warm to the touch, and the client must be able
to move the toes.
TEST-TAKING HINT: Note the adjectives "22-gauge" and "moist." If the test taker is unsure of the correct
answer, then the test taker should determine which system is affected and see if that will help
determine the right answer. A client's extremities and a neurovascular assessment are similar;
therefore, the test taker should select option "4."
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a
patent airway, which collaborative intervention is priority for the client?
1. Replace fluids and electrolytes.
,2. Prevent contractures of extremities.
3. Monitor urine output hourly.
4. Prepare to assist with an escharotomy.
**1. After airway, the most urgent need is preventing irreversible shock by replacing fluids and
electrolytes.
2. This is important, but it is not priority over fluid volume balance, and this is not a collaborative
intervention because the nurse can do this independently.
3. Output must be monitored, but this is an independent intervention.
4. An escharotomy, an incision that releases scar tissue that prevents the body from being able to
expand, enables chest excursion in circumferential chest burns. The client has not had time to develop
eschar.
TEST-TAKING HINT: A collaborative intervention is an intervention that requires an HCP's order or
working with another discipline. Therefore, options "2" and "3" should be eliminated immediately.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower
extremity burn. Which assessment data would require immediate attention by the nurse?
1. The client complains of pain when the medication is administered.
2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
4. The client is able to perform active range-of-motion exercises.
1. The client should be premedicated with an analgesic because this agent causes severe burning pain
for up to 20 minutes after application.
2. Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. Also, these
electrolytes are WNL and would not require immediate intervention.
**3. Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause
metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immediate
intervention.
4. The client being able to perform range-ofmotion exercises does not warrant immediate intervention;
this is a very good result.
TEST-TAKING HINT: "Require immediate attention" means that the nurse must intervene independently
or notify another health-care provider. The test taker must know how to interpret ABGs, and, even if the
test taker is not familiar with the medication, metabolic acidosis requires intervention.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is
a xenograft?" Which statement by the nurse would be the best response?
1. "The doctor will graft skin from your back to your leg."
2. "The skin from a donor will be used to cover your burn."
3. "The graft will come from an animal, probably a pig."
4. "I think you should ask your doctor about the graft."
1. This is the explanation for an autograft.
2. This is the description of a homograft.
**3. A xenograft or heterograft consists of skin taken from animals, usually porcine.
4. This is "passing the buck"; the nurse can and should answer this question with factual information.
TEST-TAKING HINT: The test taker should eliminate options to help determine the correct answers.
,Option "1" can be eliminated because skin from self would be auto-, not xeno-. Option "4" should be
eliminated because the nurse should answer the question and not pass the buck.
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-
thickness and deep partial-thickness burns over half the body. Which client problem has priority?
1. High risk for infection.
2. Ineffective coping.
3. Impaired physical mobility.
4. Knowledge deficit.
**1. Although this is a potential problem, it is priority because the body's protective barrier, the skin,
has been compromised and there is an impaired immune response.
2. This psychosocial client problem is important, but in the ICU the first priority is preventing infection so
wound healing can occur.
3. Burn wound edema, pain, and potential joint contractures can cause mobility deficits, but the first
priority is preventing infection so wound healing can occur.
4. Teaching is always important, but in the ICU the priority is the physiological integrity of the client.
TEST-TAKING HINT: The adjectives "intensive care" mean the client is critically ill; therefore, a
physiological problem is priority and options "2" and "4" can be eliminated. Although actual is usually
higher priority than potential, in the case of a burn the risk for infection has to be priority
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which
intervention would be appropriate for this nursing diagnosis?
1. Provide analgesia before pain becomes severe.
2. Clean the client's wounds, body, and hair daily.
3. Screen visitors for respiratory infections.
4. Encourage visitors to bring plants and flowers.
1. Addressing pain will not address impaired skin integrity.
**2. Daily cleaning reduces bacterial colonization.
3. This intervention would be appropriate for a "risk for infection" nursing diagnosis.
4. Plants and flowers in water should be avoided because stagnant water is a source for bacterial
growth.
TEST-TAKING HINT: The intervention addresses the etiology of the nursing diagnosis "open burn
wounds," and the goal addresses the response "impaired skin integrity."
Which nursing interventions should be included for the client who has full-thickness and deep partial-
thickness burns to 50% of the body? Select all that apply.
1. Perform meticulous hand hygiene.
2. Use sterile gloves for wound care.
3. Wear gown and mask during procedures.
4. Change invasive lines once a week.
5. Administer antibiotics as prescribed
*1. Hand washing is the number-one intervention used to prevent infection, which is priority for the
client with a burn. *2. Aseptic techniques minimize risk of crosscontamination and spread of bacteria.
**3. Aseptic techniques minimize risk of crosscontamination and spread of bacteria.
, 4. Invasive lines and tubing should be changed daily.
**5. Antibiotics reduce bacteria.
TEST-TAKING HINT: Alternative-type questions require the test taker to choose all options that apply.
Infection is a priority for clients with burns.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area.
Which assessment data would warrant notifying the health-care provider?
1. The client is complaining of severe pain.
2. The client's pulse oximeter reading is 95%.
3. The client has T 100.4˚F, P 100, R 24, and BP 102/60.
4. The client's urinary output is 50 mL in two (2) hours.
1. Severe pain would be expected in a client with these types of burns; therefore, it would not warrant
notifying the health-care provider.
2. A pulse oximeter reading greater than 93% is WNL. Therefore, a 95% reading would not warrant
notifying the health-care provider.
3. The client's vital signs show an elevated temperature, pulse, and respiration, along with a low blood
pressure, but these vital signs would not be unusual for a client with severe burns.
**4. Fluid and electrolyte balance is the priority for a client with a severe burn. Fluid resuscitation must
be maintained to keep a urine output of 30 mL/hr. Therefore, a 25-mL/hr output would warrant
immediate intervention.
TEST-TAKING HINT: The test taker must select an answer that is not expected for the client's disease or
condition when being asked which data warrant immediate nursing intervention.
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body.
The nurse is concerned with the client's nutritional status. Which intervention should the nurse
implement?
1. Encourage the client's family to bring favorite foods.
2. Provide a low-fat, low-cholesterol diet for the client.
3. Monitor the client's weight weekly in the same clothes.
4. Make a referral to the hospital social worker.
**1. The client needs sufficient nutrients for wound healing and increased metabolic requirements, and
homemade nutritious foods are usually better than hospital food. This also allows the family to feel part
of the client's recovery.
2. The client should be provided a highcalorie, high-protein diet along with vitamins.
3. The client should be weighed daily, and the goal is that the client loses no more than 5% of preburn
weight.
4. The nurse would make a referral to a dietitian, not a social worker. TEST-TAKING HINT: The nurse
needs to be knowledgeable of different types of diets; this requires memorization.
The client sustained a hot grease burn to the right hand and calls the emergency room for advice.
Which information should the nurse provide to the client?
1. Apply an ice pack to the right hand.
2. Place the hand in cool water.
3. Be sure to rupture any blister formation.
4. Go immediately to the doctor's office.
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