hesi medsurg level 4

Hesi medsurg level 4 exam   Hesi medsurg level 4 exam A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? You Selected: • 36% Correct response: • 36% Explanation: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Rule of Nines, p. 1848. Chapter 62: Management of Patients with Burn Injury - Page 1848 Add a Note Question 2 See full question 22s Report this Question When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? You Selected: • Ineffective airway clearance related to edema of the respiratory passages Correct response: • Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process isn't appropriate because burns aren't a disease. Disturbed sleep pattern related to facility environment and Risk for infection related to breaks in the skin may be appropriate, but they don't command a higher priority than Ineffective airway clearance because they don't reflect immediately life-threatening problems. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-6, p. 1857. Chapter 62: Management of Patients with Burn Injury - Page 1857 Add a Note Question 3 See full question 1m 17s Report this Question In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? You Selected: • A urine output consistently above 40 ml/hour Correct response: • A urine output consistently above 40 ml/hour Explanation: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 4 See full question 1m 45s Report this Question The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to You Selected: • decrease catabolism. Correct response: • decrease catabolism. Explanation: The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1865. Chapter 62: Management of Patients with Burn Injury - Page 1865 Add a Note Question 5 See full question 30s Report this Question Which of the following is a true statement regarding the purposes of skin grafts? You Selected: • Reduces scarring and contractures. Correct response: • Reduces scarring and contractures. Explanation: Purposes of a skin graft include the reduction of scarring and contractures, to decrease evaporative fluid loss, decrease the potential for infection, and speed recovery. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Wound Grafting, p. 1863. Chapter 62: Management of Patients with Burn Injury - Page 1863 Add a Note Question 6 See full question 2m 50s Report this Question A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? You Selected: • The client's breathing is unlabored and skin is clammy. Correct response: • The client's urinary output is 0.5 mL/kg/hour. Explanation: Successful fluid resuscitation is gauged by a urinary output of 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 7 See full question 8s Report this Question Which of the following is the analgesic of choice for burn pain? You Selected: • Morphine sulfate Correct response: • Morphine sulfate Explanation: Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient’s self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-5, p. 1855. Chapter 62: Management of Patients with Burn Injury - Page 1855 Add a Note Question 8 See full question 31s Report this Question A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? You Selected: • Superficial Correct response: • Superficial Explanation: A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847. Chapter 62: Management of Patients with Burn Injury - Page 1847 Add a Note Question 9 See full question 1m 32s Report this Question Specific potential complications are common to specific types of burns. Which burns can impair ventilation? You Selected: • face, neck, chest Correct response: • face, neck, chest Explanation: Burns of the face, neck, or chest have the potential to impair ventilation. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018. Add a Note Question 10 See full question 46s Report this Question A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? You Selected: • inflammatory Correct response: • inflammatory Explanation: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1850. Chapter 62: Management of Patients with Burn Injury - Page 1850 Add a Note Question 11 See full question 1m 35s Report this Question A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? You Selected: • Alteration in Tissue Perfusion Correct response: • Risk for Impaired Gas Exchange Explanation: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, On-the-Scene Care, p. 1853. Chapter 62: Management of Patients with Burn Injury - Page 1853 Add a Note Question 12 See full question 57s Report this Question An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? You Selected: • The client has experienced extensive full-thickness burns. Correct response: • The client has experienced extensive full-thickness burns. Explanation: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1: Characteristics of Burns According to Depth, p. 1847. Chapter 62: Management of Patients with Burn Injury - Page 1847 Add a Note Question 13 See full question 40s Report this Question The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? You Selected: • Electrical burns usually follow an internal path. Correct response: • Electrical burns usually follow an internal path. Explanation: Electrical current follows the path of less resistance. Because the skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-3: Electrical Burns, p. 1850. Chapter 62: Management of Patients with Burn Injury - Page 1850 Add a Note Question 14 See full question 1m 38s Report this Question The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? You Selected: • Roll the client in a blanket. Correct response: • Roll the client in a blanket. Explanation: When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls (“stop, drop, and roll”); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to “stop, sit, and pat” to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 15 See full question 8s Report this Question When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area? You Selected: • 1 Correct response: • 1 Explanation: In clients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the client's palm, including the surface area of the digits, is approximately 1% of the total body surface area. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1849. Chapter 62: Management of Patients with Burn Injury - Page 1849 Add a Note Question 16 See full question 1m 55s Report this Question The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse’s initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse’s best response based on the clinical findings? You Selected: • Elevate the leg on pillows and reassess the leg in 1 hour. Correct response: • Contact the primary care provider and prepare for an escharotomy. Explanation: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1851. Chapter 62: Management of Patients with Burn Injury - Page 1851 Add a Note Question 17 See full question 1m 49s Report this Question The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? You Selected: • “As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn’t help.” Correct response: • “As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn’t help.” Explanation: Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated. The other statements indicate that teaching has been effective. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1866. Chapter 62: Management of Patients with Burn Injury - Page 1866 Add a Note Question 18 See full question 1m 17s Report this Question The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient’s burns are full-thickness burns? You Selected: • Identification by the destruction of the dermis and epidermis Correct response: • Identification by the destruction of the dermis and epidermis Explanation: Third-degree (full-thickness) burns involve total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue. Second-degree burns are associated with blister formation. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847. Chapter 62: Management of Patients with Burn Injury - Page 1847 Add a Note Question 19 See full question 55s Report this Question The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer’s (LR) × patient’s weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post–burn injury? Your Response: • 3422 Correct response: • 3422 Explanation: Convert pounds. to kilograms = 130/2.2 = 59 kg 2 mL x 59 kg x 58% TBSA = 6844 mL/24 hr. 6844/2 = 3422, so the nurse will administer 3422 mL over the first 8 hours and the remaining 3422 mL over the next 16 hours. The infusion is regulated so that one-half of the calculated volume is administered in the first 8 hours after burn injury. The second half of the calculated volume is administered over the next 16 hours. Fluid resuscitation formulas are only a guideline. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 20 See full question 51s Report this Question A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. What depth of burn injury does the client have? You Selected: • fourth degree Correct response: • full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1848. Chapter 62: Management of Patients with Burn Injury - Page 1848 Question 1 See full question 3m 29s Report this Question In a client with burns on the legs, which nursing intervention helps prevent contractures? You Selected: • Elevating the foot of the bed Correct response: • Applying knee splints Explanation: Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Promoting Physical Mobility, pp. . Chapter 62: Management of Patients with Burn Injury - Page Add a Note Question 2 See full question 2m 16s Report this Question A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested? You Selected: • Neck and chest Correct response: • Neck and chest Explanation: Skin grafting is essential for deep partial-thickness burns on the client's neck and chest because the skin layers responsible for regeneration have been destroyed. The client's face does not need skin grafting because the burns are superficial and will heal unassisted. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Wound Grafting, p. 1863. Chapter 62: Management of Patients with Burn Injury - Page 1863 Add a Note Question 3 See full question 20s Report this Question A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? You Selected: • The client's urinary output is 0.5 mL/kg/hour. Correct response: • The client's urinary output is 0.5 mL/kg/hour. Explanation: Successful fluid resuscitation is gauged by a urinary output of 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 4 See full question 13s Report this Question Which of the following measures can be used to cool a burn? You Selected: • Using cold soaks or dressings for at least 1 hour Correct response: • Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 5 See full question 10s Report this Question Which type of burn injury requires skin grafting? You Selected: • Full-thickness Correct response: • Full-thickness Explanation: A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847. Chapter 62: Management of Patients with Burn Injury - Page 1847 Add a Note Question 6 See full question 1m 51s Report this Question The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? You Selected: • Skin grafting will be necessary. Correct response: • Skin grafting will be necessary. Explanation: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1: Characteristics of Burns According to Depth, p. 1847. Chapter 62: Management of Patients with Burn Injury - Page 1847 Add a Note Question 7 See full question 1m 7s Report this Question The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? You Selected: • A urinary output of 30 mL/hr Correct response: • A urinary output of 30 mL/hr Explanation: For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a). Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-6, p. 1857. Chapter 62: Management of Patients with Burn Injury - Page 1857 Add a Note Question 8 See full question 53s Report this Question A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? You Selected: • Homografts Correct response: • Homografts Explanation: Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). An autograft uses the client’s own skin, which is transplanted from one part of the body to another. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Homografts and Xenografts, p. 1864. Chapter 62: Management of Patients with Burn Injury - Page 1864 Add a Note Question 9 See full question 37s Report this Question A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: You Selected: • Epidermis and a portion of deeper dermis. Correct response: • Epidermis and a portion of deeper dermis. Explanation: A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847. Chapter 62: Management of Patients with Burn Injury - Page 1847 Add a Note Question 10 See full question 49s Report this Question A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: You Selected: • Monitor cardiac status. Correct response: • Replace lost fluids and electrolytes. Explanation: After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Fluid and Electrolyte Alterations, p. 1851. Chapter 62: Management of Patients with Burn Injury - Page 1851 Question 1 See full question 1m 31s Report this Question A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? You Selected: • 27% Correct response: • 27% Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Rule of Nines, p. 1848. Chapter 62: Management of Patients with Burn Injury - Page 1848 Add a Note Question 2 See full question 46s Report this Question When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? You Selected: • Hoarseness of the voice Correct response: • Hoarseness of the voice Explanation: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-6, p. 1857. Chapter 62: Management of Patients with Burn Injury - Page 1857 Add a Note Question 3 See full question 48s Report this Question A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? You Selected: • Hemodilution Correct response: • Hemodilution Explanation: Reduced hematocrit is caused by hemodilution 48 hours after a burn, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbuminemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced hematocrit level in this situation. Erythropoietin factor is reduced if kidney failure occurs; however, lack of erythropoietin factor doesn't affect hematocrit level. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Fluid and Electrolyte Alterations, p. 1852, 1856. Chapter 62: Management of Patients with Burn Injury - Page 1852, 1856 Add a Note Question 4 See full question 1m 19s Report this Question The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? You Selected: • Music therapy may provide reality orientation, distraction, and sensory stimulation. Correct response: • Music therapy may provide reality orientation, distraction, and sensory stimulation. Explanation: Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1865. Chapter 62: Management of Patients with Burn Injury - Page 1865 Add a Note Question 5 See full question 38s Report this Question Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? You Selected: • Deep partial-thickness Correct response: • Deep partial-thickness Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis as well as injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018. Add a Note Question 6 See full question 13s Report this Question When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area? You Selected: • 2 Correct response: • 1 Explanation: In clients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the client's palm, including the surface area of the digits, is approximately 1% of the total body surface area. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1849. Chapter 62: Management of Patients with Burn Injury - Page 1849 Add a Note Question 7 See full question 2m 4s Report this Question A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? You Selected: • The early appearance of the burn injury may change. Correct response: • The early appearance of the burn injury may change. Explanation: The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Lund and Browder Method, p. 1849. Chapter 62: Management of Patients with Burn Injury - Page 1849 Add a Note Question 8 See full question 21s Report this Question Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? You Selected: • Enzymatic Correct response: • Natural Explanation: Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Natural Debridement, p. 1862. Chapter 62: Management of Patients with Burn Injury - Page 1862 Add a Note Question 9 See full question 15s Report this Question A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? You Selected: • 27% Correct response: • 27% Explanation: The TBSA would be 27%. 18% for the anterior trunk and 9% for the left arm. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Rule of Nines, p. 1848. Chapter 62: Management of Patients with Burn Injury - Page 1848 Add a Note Question 10 See full question 25s Report this Question A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? You Selected: • Full-thickness Correct response: • Full-thickness Explanation: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Burn Depth, p. 1848. Chapter 62: Management of Patients with Burn Injury - Page 1848 Add a Note Question 11 See full question 23s Report this Question An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? You Selected: • 36% Correct response: • 36% Explanation: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Rule of Nines, p. 1848. Chapter 62: Management of Patients with Burn Injury - Page 1848 Add a Note Question 12 See full question 1m 45s Report this Question A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? You Selected: • “Are the burns associated with chemicals used in the plant?” Correct response: • “Are the burns associated with chemicals used in the plant?” Explanation: If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, On-the-Scene Care, p. 1853. Chapter 62: Management of Patients with Burn Injury - Page 1853 Add a Note Question 13 See full question 2m 25s Report this Question Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? You Selected: • Application of ice Correct response: • Application of ice Explanation: Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury. Clothing and hair are removed from perimeter of burned area in an effort to remove course of bacterial contamination. Irrigation of the wound assists in the removal of debris. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4: Emergency Procedures at the Burn Scene, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 14 See full question 23s Report this Question Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? You Selected: • Fluid resuscitation Correct response: • Fluid resuscitation Explanation: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 15 See full question 19s Report this Question Following a burn injury, the nurse determines which area is the priority for nursing assessment? You Selected: • Cardiovascular system Correct response: • Pulmonary system Explanation: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Quality and Safety Nursing Alert, p. 1853. Chapter 62: Management of Patients with Burn Injury - Page 1853 Add a Note Question 16 See full question 24s Report this Question A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? You Selected: • BUN: 28 mg/dL Correct response: • BUN: 28 mg/dL Explanation: The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018. Add a Note Question 17 See full question 2m 44s Report this Question The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? You Selected: • Paralytic ileus Correct response: • Paralytic ileus Explanation: Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Gastrointestinal Alterations, p. 1853. Chapter 62: Management of Patients with Burn Injury - Page 1853 Add a Note Question 18 See full question 39s Report this Question A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as: You Selected: • Dry and pale white. Correct response: • Dry and pale white. Explanation: The wound appearance for a full-thickness burn would be dry, pale white, leathery, or charred. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847. Chapter 62: Management of Patients with Burn Injury - Page 1847 Add a Note Question 19 See full question 24s Report this Question Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: You Selected: • Hyperkalemia. Correct response: • Hyperkalemia. Explanation: Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Fluid and Electrolyte Alterations, p. 1851. Chapter 62: Management of Patients with Burn Injury - Page 1851 Add a Note Question 20 See full question 1m 11s Report this Question As the first priority of care, a patient with a burn injury will initially need: You Selected: • fluids replaced. Correct response: • a patent airway established. Explanation: Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, On-the-Scene Care, p. 1853. Chapter 62: Management of Patients with Burn Injury - Page 1853 Question 1 See full question 26s Report this Question A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: You Selected: • fluid resuscitation. Correct response: • pain management. Explanation: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847. Chapter 62: Management of Patients with Burn Injury - Page 1847 Add a Note Question 2 See full question 23s Report this Question A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? You Selected: • Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. Correct response: • Irrigate the wounds with water. Explanation: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 3 See full question 26s Report this Question Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? You Selected: • Roll the client in a blanket Correct response: • Roll the client in a blanket Explanation: At the scene of a fire, the client should be rolled in a blanket to smother the fire. The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 4 See full question 17s Report this Question A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? You Selected: • Gastric ulcers Correct response: • Gastric ulcers Explanation: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Gastrointestinal Alterations, pp. . Chapter 62: Management of Patients with Burn Injury - Page Add a Note Question 5 See full question 6s Report this Question Which type of graft utilizes the client's own skin for wound coverage? You Selected: • Allograft Correct response: • Autograft Explanation: An autograft uses the client's own skin, which is transplanted from one part of the body to another. A heterograft is obtained from animals, principally pigs. An allograft is human skin obtained from a cadaver. A slit graft is used when the area available as a donor site is limited, as in clients with extensive burns. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Autografts, p. 1863. Chapter 62: Management of Patients with Burn Injury - Page 1863 Add a Note Question 6 See full question 11s Report this Question Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? You Selected: • Biobrane Correct response: • Biobrane Explanation: Biobrane is a nylon-silicone membrane coated with a protein. Mederma is a topical gel that can reduce scarring. Integra consists of a two-layer membrane: one is a synthetic epidermal layer , and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. Transcyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Biosynthetic and Synthetic Dressings, p. 1864. Chapter 62: Management of Patients with Burn Injury - Page 1864 Add a Note Question 7 See full question 13s Report this Question Which of the following is to be expected soon after a major burn? Select all that apply. You Selected: • Anxiety • Hypotension • Tachycardia Correct response: • Hypotension • Tachycardia • Anxiety Explanation: Tachycardia, slight hypotension, and anxiety are expected soon after the burn. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Nursing Management, p. 1856. Chapter 62: Management of Patients with Burn Injury - Page 1856 Add a Note Question 8 See full question 12s Report this Question Which antimicrobials is not commonly used to treat burns? You Selected: • silver sulfadiazine (Silvadene) Correct response: • tetracycline Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1862. Chapter 62: Management of Patients with Burn Injury - Page 1862 Add a Note Question 9 See full question 55s Report this Question A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? You Selected: • debridement Correct response: • escharotomy Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1851. Chapter 62: Management of Patients with Burn Injury - Page 1851 Add a Note Question 10 See full question 57s Report this Question At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply. You Selected: • Roll the client in a blanket to smother the fire. • Place the client in a horizontal position. Correct response: • Place the client in a horizontal position. • Roll the client in a blanket to smother the fire. Explanation: If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854. Chapter 62: Management of Patients with Burn Injury - Page 1854 Add a Note Question 11 See full question 4s Report this Question Skin grafts are necessary for which of the following burns? You Selected: • Full-thickness Correct response: • Full-thickness Explanation: Skin grafts are necessary for a full-thickness burn because the skin cells no longer are alive to regenerate. Superficial (first degree), superficial partial-thickness burns do not usually need skin grafting. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1: Characteristics of Burns According to Depth, p. 1847. Chapter 62: Management of Patients with Burn Injury - Page 1847 Add a Note Question 12 See full question 17s Report this Question Following a serious thermal burn, which complication will the nurse take action to prevent first? You Selected: • Hypovolemia Correct response: • Hypovolemia Explanation: After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Cardiovascular Alterations, p. 1850. Chapter 62: Management of Patients with Burn Injury - Page 1850 Add a Note Question 13 See full question 15s Report this Question When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn? You Selected: • Parkland formula Correct response: • Use client’s palm size Explanation: A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client’s palm size to approximate the total body surface. The palm is approximately 1% of a person’s TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Browder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of nines quantitates burns that involve entire sections of the body, not scattered burns. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Palmer Method, p. 1849. Chapter 62: Management of Patients with Burn Injury - Page 1849 Add a Note Question 14 See full question 3m 49s Report this Question Which is the primary reason for placing a client in a horizontal position while smothering flames are present? You Selected: • To promote blood flow to the brain and vital organs Correct response: • To keep fire and smoke from airway Explanation: The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. Stop, drop, and roll method is a quick efficient means to distinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018. Add a Note Question 15 See full question 48s Report this Question The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote You Selected: • decreased catabolism. Correct response: • decreased catabolism. Explanation: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body’s response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism. Reference: • Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1865. Chapter 62: Management of Patients with Burn Injury - Page 1865 Add a Note Question 16 See full question 14s Report this Question The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies? You Selected: • Hyperkalemia Correct r