,
MULTIPLE CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. Which term would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickn...
Harding: Lewis’s Medical -Surgical Nursing, 12th Edition MULTIPLE CHOICE 1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. Which term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial -thickness skin destruction d. Superficial partial -thickness skin destruction ANS: B With full -thickness ski n destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial -
thickness burn. With superficial partial -thickness burns, the area is red, but no blisters are present. First -degree burns exhibit erythema, blanching, and pain. DIF: Cognitive Level : Understand (Comprehension) TOP: Nursing Process : Assessment MSC : NCLEX : Physiological Integrity 2. On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which prescribed action would be the nurse’s priority ? a. Monitoring urine output b. Scheduling additional laboratory tests c. Increasing the rate of the ordered IV solution d. Typing and cross matching for a blood transfusion ANS: C The patient‘s laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Additional lab tests can be scheduled after the fluid volume is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, althou gh transfusions may be needed after the emergent phase once the patient’s fluid balance has been restored. Urine output would be monitored frequently, likely every hour, and adequate fluid volume will be needed to maintain the urine output. DIF: Cognitive Level : Analyze (Analysis) TOP: Nursing Process : Planning MSC : NCLEX : Physiological Integrity 3. A patient is admitted with burns to the head , face, and hands. Initially, wheezes are heard throughout the chest , but an hour later, the lung sounds are decreased , and no wheezes are audible. Which action would the nurse take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the assessment and continue to monitor the pat ient’s respiratory rate. d. Reposition the patient in high -Fowler‘s position and reassess breath sounds. ANS: B The patient‘s history and clinical manifestations suggest airway edema, and the health care provider should be notified at once so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur. DIF: Cognitive Level : Apply (Application) TOP: Nursing Process : Implementation MSC: NCLEX: Physiological Integrity 4. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given in the first 24 hours is 30,00 0 mL. The initial rate of administration is 1875 mL/hr. After
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