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NUR 265 Exam 3 87 Questions and Answers A+ Graded 2024/2025 $10.99   Add to cart
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NUR 265 Exam 3 87 Questions and Answers A+ Graded 2024/2025
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NUR 265 Exam 3/87 Questions and Answers/A+ Graded Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action? - Correct Answer -Document the findings Why? Decreased or absent peristalsis is an expected respo...

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  • January 17, 2024
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  • 2023/2024
  • Exam (elaborations)
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NUR 265 Exam 3/87 Questions and Answers/A+
Graded

Twelve hours after the client was initially burned, bowel sounds are absent in
all four abdominal quadrants. Which is the nurse's best action? - Correct
Answer -Document the findings

Why?
Decreased or absent peristalsis is an expected response during the
emergent phase of burn injury as a result of neural and hormonal
compensation to the stress of injury. No currently accepted intervention
changes this response. It is not the highest priority of care at this

Three days after a burn injury, the client develops a temperature of 100° F,
white blood cell count of 15,000/mm3, and a white, foul-smelling discharge
from the wound. The nurse recognizes that the client is most likely exhibiting
symptoms of which - Correct Answer -Wound infection

wound to the LPN. Which instruction is most important for the RN to provide
the LPN? - Correct Answer -Wash hands upon entering the clients room

What intervention will the nurse implement to reduce a client's pain after a
burn injury? - Correct Answer -Administer 4mg Morphine IV

What statement indicates the client needs further education regarding the
skin grafting (allografting)? - Correct Answer -"Because the graft is my own
skin, there is no chance it won't 'take.'

When providing care for a client with an acute burn injury, which nursing
intervention is most important to prevent infection by autocontamination? -
Correct Answer -Changing gloves between wound care on different parts of
the client's body

Which assessment finding assists the nurse in confirming inhalation injury? -
Correct Answer -Brassy cough

Which finding indicates that fluid resuscitation has been successful for a
client with a burn injury? - Correct Answer -Urine output = 50ml/HR

Which finding indicates to the nurse that a client with a burn injury has a
positive perception of his appearance? - Correct Answer -Performing his own
morning care.

Why?

, Indicators that the client with a burn injury has a positive perception of his
appearance includes the willingness to touch the affected body part. Self-
care activities such as morning care foster feelings of self-worth, which are
closely linked to body image. Allowing others to change the dressing and
discussing future reconstruction would not indicate a positive perception of
appearance. Wearing the

Which finding indicates to the nurse that the client understands the
psychosocial impact of his severe burn injury? - Correct Answer -It is normal
to feel depressed.

Which finding is characteristic during the emergent period after a deep full
thickness burn injury? - Correct Answer -Urine output of 10ml/hr

Why?
During the fluid shift of the emergent period, blood flow to the kidney may
not be adequate for glomerular filtration. As a result, urine output is greatly
decreaseD. Foul-smelling discharge does not occur during the emergent
phase and blood pressure is usually low. Pain does not occur with deep full-
thickness burns.

Which is the priority nursing diagnosis during the first 24 hours for a client
with chemical burns to the legs and arms that are red in color, edematous,
and without pain? - Correct Answer -Decreased tissue perfusion

Why?

During the emergent phase, fluid shifts into interstitial tissue in burned
areas. When the burn is circumferential on an extremity, the swelling can
compress blood vessels to such an extent that circulation is impaired distal
to the injury, causing decreased tissue perfusion and necessitating the
intervention of an escharotomy. Chemical burns do not cause inhalation
injury and a disrupted breathing pattern. Disturbed body image and disuse
syndrome can develop. However, these are not priority diagnoses at this
time.

Which laboratory result, obtained on a client 24 hours post-burn injury, will
the nurse report to the physician immediately? - Correct Answer -Serum
potassium,7.5 mmol/L (mEq/L)

Which nursing intervention is likely to be most helpful in providing adequate
nutrition while the client is recovering from a thermal burn injury? - Correct
Answer -Allowing the client to eat whenever he or she wants

Why?

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