Lewis - Chapter 27 Nursing Management Burns Exam Questions with Correct Answers
5 views 0 purchase
Course
Burns
Institution
Burns
The nurse is assessing a client who spilled hot oil on the right leg and foot and notes that
the skin is red, swollen, and covered with large blisters. The client states that they are very
painful. Which of the following burn descriptions should the nurse document?
a. Full-thickness skin destr...
Lewis - Chapter 27 Nursing Management
Burns Exam Questions with Correct
Answers
The nurse is assessing a client who spilled hot oil on the right leg and foot and notes
that
the skin is red, swollen, and covered with large blisters. The client states that they are
very
painful. Which of the following burn descriptions should the nurse document?
a. Full-thickness skin destruction
b. Deep full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction - Answer-ANS: C
The erythema, swelling, and blisters point to a deep partial-thickness burn. With
full-thickness skin destruction, the appearance is pale and dry or leathery and the area
is
painless because of the associated nerve destruction. With superficial partial-thickness
burns, the area is red, but no blisters are present.
The nurse is admitting a client to the burn unit who has burns to the upper body and
head
after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are
decreased and no wheezes are audible. Which of the following actions should the nurse
implement first?
a. Encourage the client to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the client's respiratory rate.
d. Reposition the client in high-Fowler's position and reassess breath sounds. - Answer-
ANS: B
The client's history and clinical manifestations suggest airway edema and the health
care
provider should immediately be notified so that intubation can rapidly be done. Placing
the
client in a more upright position or having the client cough will not address the problem
of
airway edema. Continuing to monitor is inappropriate because immediate action should
occur.
The nurse is caring for a client with severe burns who is receiving crystalloid fluid
replacement IV, ordered using the Parkland formula. The initial volume of fluid to be
administered in the first 24 hours is 30 000 mL. The initial rate of administration is 1 875
, mL/hour. Which of the following infusion rates is accurate after the first 8 hours?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1 250 mL/hour - Answer-ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first 8
hours and the other half over the next 16 hours (25% per each 8 hour period,
respectively).
In this case, the client should receive half of the initial rate, or 938 mL/hour.
The nurse is caring for a client who is in the emergent phase of burn care. Which of the
following nursing actions will be most useful in determining whether the client is
receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output. - Answer-ANS: D
When fluid intake is adequate, the urine output will be at least 0.5-1 mL/kg/hour. The
client's weight is not useful in this situation because of the effects of third spacing and
evaporative fluid loss. Mucous membrane assessment and skin turgor also may be
used,
but they are not as adequate in determining that fluid infusions are maintaining
adequate
perfusion.
The nurse is caring for a client who has just been admitted with a 40% total body
surface
area (TBSA) burn injury. Which of the following interventions should the nurse include in
the plan of care to maintain adequate nutrition?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5 000 kcal/day.
d. Administer multiple vitamins and minerals in the IV solution. - Answer-ANS: A
Enteral feedings can usually be initiated during the emergent phase at low rates and
increased over 24-48 hours to the goal rate. During the emergent phase, the client will
be
unable to eat enough calories to meet nutritional needs and may have a paralytic ileus
that
prevents adequate nutrient absorption. Vitamins and minerals may be administered
during
the emergent phase, but these will not assist in meeting the client's caloric needs.
Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal
function, and is not routinely used in burn-injured clients.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller lectknancy. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $12.49. You're not tied to anything after your purchase.
