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NR 464 Complex Health Care Management of the Adult and Older Adult IIFinal Exam
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NR 464 Complex Health Care Management of the Adult and Older Adult IIFinal Exam
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1NR 464 Complex Health Care Management of the Adult and Older Adult II
Final Exam_All Units
INSTRUCTIONS: Read each question carefully and choose the best answer. Place answer on the
Scantron sheet provided. Use only a #2 pencil to record answers. After completing the exam, return
the exam and Scantron sheet to the proctor. You may write on the exam.
1. While the client's full–thickness burn wounds to the chest and abdomen are exposed, what is
the best nursing action to prevent cross contamination and a potential infection?
A. Use sterile gloves when removing old dressings.
B. Wear gowns, caps, masks, and gloves during all care of the client.
C. Administer IV antibiotics to prevent bacterial colonization of wounds.
D. Turn the room temperature up to at least 70 degrees F during dressing changes.
2. A client is in the burn center 24 hours following a 40% total body surface area (TBSA) burn injury.
To maintain adequate nutrition at this time, the nurse anticipates the health care provide to first
try which of the following methods to best meet the client's nutritional requirements?
A. Infuse total parenteral nutrition via a central catheter.
B. Encourage an oral intake of at least 1000 kcal per day.
C. Administer multiple vitamins and minerals in the client’s lactated ringer's IV solutions.
D. Insert a nasointestinal feeding tube and initiate enteral feedings.
3. A client arrives at the emergency department with a chemical burn of the left eye. The first
action of the nurse is to immediately:
A. Apply a cold compress to the injured eye.
B. Flush the eye with water.
C. Apply a topical agent to the eye to relieve pain.
D. Monitor pH of eye.
4. A client with deep partial-thickness burns over 25% of his trunk and legs is going for
debridement in the cart shower 24 hours postburn. The drug of choice to control the client's
pain during this activity is:
A. IV midazolam (Versed).
B. IM meperidine (Demerol).
C. IV morphine.
D. Long-acting oral morphine.
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5. The nurse is preparing a burn client scheduled for an escharotomy for a full thickness
circumferential arm burn. The nurse understands that the anticipated outcome of the procedure
is
A. Brisk bleeding from the site.
B. Decreased edema formation.
C. Return of distal pulses.
D. Decreased keloid formation
6. In assessing the burn client, the nurse is suspicious of possible inhalation injury when the victim:
A. Is tachycardic with a low blood pressure.
B. Has a productive cough of black colored secretions.
C. Has a pulse oximetry reading of 93%.
D. Has a respiratory rate of 20 breaths per minute.
7. The nurse is caring for a client who has sustained burns over 40% of the body. Twelve hours post-
injury, the client's hematocrit is 58% with a urine output of 20 mL/hr. Which of the following
interventions should the nurse perform?
A. Elevate the head of the bed.
B. Obtain an order to insert a Dobhoff feeding tube.
C. Obtain an order to administer a blood transfusion.
D. Obtain an order to increase the flow rate of IV fluids.
8. A client who was found unconscious in a burning house is brought to the emergency department
by ambulance. The nurse notes that the client's skin color is bright (cherry) red. Which action
should the nurse take first?
A. Insert two large-bore IV lines.
B. Check the client's orientation.
C. Place the client on 100% oxygen using a non-rebreather mask.
D. Assess for singed nasal hair and dark oral mucous membranes.
9. The nurse is caring for a client who has sustained burns to the right arm and right hand from
spilled hot grease (5% Total Body Surface Area or TBSA). The burn area appears red, wet, and
glistening with blisters present. Which of the following nursing diagnoses should receive
priority?
A. Pain related to partial-thickness burn injury.
B. Body image disturbance related to disfiguring wound.
C. Hyperthermia related to full-thickness burn injury.
D. Fluid volume deficit related to massive fluid shifts.
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10. An adult client arrives in the emergency unit with burns to areas colored in the picture below.
Note burned areas include both legs and the perineum. Using the Rule of Nines, the nurse
should determine that approximately what percentage of the client's body surface has been
burned?
A. 10%.
B. 19%.
C. 37%.
D. 54%.
11. After receiving change-of-shift report, which of these clients should the nurse assess first?
A. A client with 15% total body surface area (TBSA) burns who is receiving fluids at 150
mL/hour.
B. A client with smoke inhalation who has wheezes and altered mental status.
C. A client with full-thickness leg burns who has a dressing change scheduled.
D. A client with abdominal burns who is complaining of pain at level 4 (0-10 scale).
12. A client is admitted to the ED with a burn (see image). This type of burn is best classified as:
A. Full thickness burn
B. Deep partial thickness burn
C. Third degree burn
D. First degree burn
08-2017 Version
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