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Test Bank for Burns and Grove’s the Practice of Nursing Research 8th, 9th Edition
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Test Bank for Burns and Grove’s the Practice of Nursing Research 8th, 9th Edition
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Test Bank for Burns and Grove’s the Practice of Nursing Research 8th, 9th Edition
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BURNS AND GROVE'S THE PRACTICE OF NURSING RESEARCH; APPRAISAL, SYNTHESIS AND GENERATION OF EVIDENCE 8TH EDITION GRAY, GROVE AND SUTHERLAND TEST BANK
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BURNS AND GROVE'S THE PRACTICE OF NURSING RESEARCH; APPRAISAL, SYNTHESIS AND GENERATION OF EVIDENCE 8TH EDITION BY GRAY,GROVE AND SUTHERLAND TEST BANK
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Test Bank for Burns and Grove’s the Practice ofNursing Research 8th, 9th Edition
The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in
a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action
should the nurse take first?
A. Administer 100% humidified oxygen.
B. Teach the patient deep breathing exercises.
C. Encourage the patient to express his feelings.
D. Assist the patient to a high Fowler's position. - ANSWER:A. Administer 100% humidified oxygen.
Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin
molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as
cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for
inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen.
The other interventions are appropriate for inhalation injury but are not as urgent as oxygen
administration.
The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the
anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the
nurse identify as congruent with this type of burn?
A. Skin is hard with a dry, waxy white appearance.
B. Skin is shiny and red with clear, fluid-filled blisters.
,C. Skin is red and blanches when slight pressure is applied.
D. Skin is leathery with visible muscles, tendons, and bones. - ANSWER:B. Skin is shiny and red with
clear, fluid-filled blisters.
Deep partial thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if
vesicles have ruptured), and mild to moderate edema may be present. Superficial partial thickness burns
are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns
are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.
The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower
leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30
minutes before the scheduled dressing change?
A. Morphine sulfate
B. Sertraline (Zoloft)
C. Zolpidem (Ambien)
D. Enoxaparin (Lovenox) - ANSWER:A. Morphine sulfate
Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to
administer analgesics before the dressing change to promote patient comfort. Morphine is a common
opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with
analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem
promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant.
Which patient should the nurse prepare to transfer to a regional burn center?
A. A 25-year-old pregnant patient with a
carboxyhemoglobin level of 1.5%
B. A 39-year-old patient with a partial-thickness burn to the
,right upper arm
C. A 53-year-old patient with a chemical burn to the
anterior chest and neck
D. A 42-year-old patient who is scheduled for skin grafting
of a burn wound - ANSWER:C. A 53-year-old patient with a chemical burn to the anterior chest and neck
The American Burn Association (ABA) has established referral criteria to determine which burn injuries
should be treated in burn centers where specialized facilities and personnel are available to handle this
type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A
normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin
grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness
burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to
the right upper arm is 4% TBSA.
The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury.
She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would
indicate adequate fluid resuscitation? (select all that apply)
A. Urine output is 80 mL/hour.
B. Heart rate is 86 beats/minute.
C. Urine specific gravity is 1.025.
D. Mean arterial pressure is 54 mm Hg.
E. Systolic blood pressure is 88 mm Hg. - ANSWER:A, B, C
A. Urine output is 80 mL/hour.
B. Heart rate is 86 beats/minute.
C. Urine specific gravity is 1.025.
Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac
factors. Urine output should be at least 0.5 to 1 mL/kg/hr. Cardiac factors include a mean arterial
, pressure (MAP) > 65 mm Hg, systolic blood pressure (BP) > 90 mm Hg, heart rate < 120 beats/minute.
Normal range for urine specific gravity is 1.003 to 1.030.
509. An adult client was burned in an explosion. The burn initially affected the client's 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 client's clothes caught on fire, and the client ran, causing subsequent
burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the
rule of nines, what would be the extent of the burn injury?
1.18%
2.24%
3.36%
4.48% - ANSWER:3.36%
Rationale:Accordingtotheruleofnines,withtheinitialburn,theanteriorhalfoftheheadequals4.5%,theupperh
alfoftheanteriortorsoequals9%,andthelowerhalfofbotharmsequals9%.Thesubsequentburnincludedthepo
steriorhalfofhead,equaling4.5%,andtheupperhalfofposteriortorso,equaling9%.Thistotals36%
510. 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?
1.Return of distal pulses
2.Brisk bleeding from the site
3.Decreasing edema formation
4.Formation of granulation tissue - ANSWER:1.Return of distal pulses
Rationale:Escharotomiesareperformedtorelievethecompartmentsyndromethatcanoccurwhenedemafor
msundernondistensibleescharinacircumferentialthird-
degreeburn.Escharotomiesareperformedthroughavasculareschartosubcutaneousfat.Althoughbleedingm
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