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Burns and Groves the Practice of Nursing Research 9th Edition
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Burns and Groves the Practice of Nursing Research 9th Edition
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BURNS AND GROVE'S THE PRACTICE OF NURSING RESEARCH, 9TH EDITION GRAY’S TESTBANK/ALL CHAPTERS 1-29 | COMPLETE GUIDE 2024-2025
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Test Bank for Burns and Grove’s the Practice of Nursing Research 9th Edition
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Burns and Grove's The Practice of Nursing Research Appraisal, Synthesis, and Generation of Evidence 9th Edition By Jennifer R. Gray; Susan K. Grove
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Test Bank for Burns and Groves the Practice of NursingResearch 9th Edition 9780323673174 | All Chapters with
Answers and Rationals
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is
dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to
document the burn depth? - ANSWER: full thickness skin destruction
with full thickness skin destruction the appearance is what? - ANSWER: 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.
superficial partial thickness burns the appearance is what? - ANSWER: red, but no blisters are present.
First-degree burns exhibit erythema, blanching, and pain.
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, serum K+ 4.9 mEq/L, and
serum Na+ 135 mEq/L. Which action will the nurse anticipate taking now? - ANSWER: Increase the
rate of the ordered IV solution. The patient's laboratory data show hemoconcentration, which may
lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the
hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be
needed after the emergent phase once the patient's fluid balance has been restored. On admission to
a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are
heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best
action for the nurse to take? - ANSWER: Notify the health care provider and prepare for endotracheal
intubation. The patient's history and clinical manifestations suggest airway edema and the health care
provider should be notified immediately, 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.
A patient with severe burns has crystalloid fluid replacement 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 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? -
ANSWER: 938 mL/hour
Parkland fluid replacement formula; the first 8 hours you administer how much fluid? - ANSWER: Half
of the fluid
Parkland fluid replacement formula: the remaining 16 hours how much fluid is administered? -
ANSWER: half the fluid
During the emergent phase of burn care, which assessment will be most useful in determining
whether the patient is receiving adequate fluid infusion? - ANSWER: Measure hourly urine output.
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain
adequate nutrition, the nurse should plan to take which action? - ANSWER: Insert a feeding tube and
initiate enteral feedings.
While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing
action to prevent cross contamination? - ANSWER: Wear gowns, caps, masks, and gloves during all
care of the patient.
, A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The
nurse should place the patient in which position? - ANSWER: Elevate the right arm and hand on
pillows and extend the fingers. The right hand and arm should be elevated to reduce swelling and the
fingers extended to avoid flexion contractures (even though this position may not be comfortable for
the patient). The patient with burns of the ears should not use a pillow for the head because this will
put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use
a pillow because the head should be maintained in an extended position in order to avoid
contractures.
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength
and numbness in the toes. Which action should the nurse take? - ANSWER: Notify the health care
provider. The decrease in pulse in a patient with circumferential burns indicates decreased circulation
to the legs and the need for an escharotomy.
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago.
Which nursing assessment would best evaluate the effectiveness of the medication? - ANSWER:
Stools for occult blood. H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in
the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel
sounds, stool frequency, or appetite.
The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness
burns. Which medication is best for the nurse to administer before scheduled wound debridement? -
ANSWER: Hydromorphone (Dilaudid). Opioid pain medications are the best choice for pain control.
A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and
neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates
that the problem is resolving? - ANSWER: Do you think dark beige makeup foundation would cover
this scar on my cheek?" The willingness to use strategies to enhance appearance is an indication that
the disturbed body image is resolving.
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine
output has dramatically increased. Which action by the nurse would best ensure adequate kidney
function? - ANSWER: Continue to monitor the urine output. The patient's urine output indicates that
the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At
the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese
large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may
be longer in some patients.
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn
treatment. Which snack would be best for the nurse to offer to this patient? - ANSWER: Vanilla
milkshake, A patient with a burn injury needs high protein and calorie food intake
A patient has just arrived in the emergency department after an electrical burn from exposure to a
high-voltage current. What is the priority nursing assessment? - ANSWER: Extremity movement; All
patients with electrical burns should be considered at risk for cervical spine injury, and assessments of
extremity movement will provide baseline data.
An employee spills industrial acids on both arms and legs at work. What is the priority action that the
occupational health nurse at the facility should take? - ANSWER: the initial action is to remove the
chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes,
watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and
surrounding area with copious amounts of saline solution or water.
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and
restless 8 hours after being admitted to the hospital. Which action should the nurse take first? -
ANSWER: Use pulse oximetry to check the oxygen saturation. Agitation in a patient who may have
suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first.
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