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LIPPINCOTTS NCLEX RN REVIEW FOR MED SURG TEST 1 /45 QUESTIONS AND ANSWERS (A+)
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- LIPPINCOTTS NCLEX RN REVIEW FOR MED SURG TEST
LIPPINCOTTS NCLEX RN REVIEW FOR MED SURG TEST 1 /45 QUESTIONS AND ANSWERS (A+)
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LIPPINCOTTS NCLEX RNREVIEW FOR MED SURG TEST
1 /45 QUESTIONS AND
ANSWERS (A+)
1 . There has been a fire in an apartment building.
All residents have been evacuated, but many are
burned. Which clients should be transported to a
burn center for treatment? Select all that apply.
• 1. An 8-year-old with third-degree burns over 10%
of his body surface area (BSA).
• 2. A 20-year-old who inhaled the smoke of the
fire.
• 3. A 50-year-old diabetic with first- and second
degree burns on his left forearm (about 5% of
his BSA).
• 4. A 30-year-old with second-degree burns on the
back of his left leg.
• 5. A 40-year-old with second-degree burns on his
right arm (about 10% of his BSA). - =1 . 1, 2, 3.
Clients who should be transferred to a
burn center include children under age 10 or adults
over age 50 with second- and third-degree burns
on 10% or greater of their body surface area (BSA),
clients between ages 11 and 49 with second- and
third-degree burns over 20% of their BSA, clients
,on my age with third-degree burns on more than
5% of their BSA, clients with smoke inhalation, and
clients with chronic diseases, such as diabetes and
heart or kidney disease.
-2 . The nurse in the immediate care clinic is
assessing an 80-year-old client who lives with his
son's family and has scald burns on his hands and
both forearms (first- and second-degree burns on
10% of his body surface area). What should the
nurse do first?
• 1. Clean the wounds with warm water.
• 2. Apply antibiotic cream.
• 3. Refer the client to a burn center.
4. Cover the burns with a sterile dressing. - =2 . 3.
The nurse should have the client transited to a burn
center. The client's age and the extent of the burns
require care by a burn team
id the client meets triage criteria for referral to a
burn center. Because of the age of the client and
the
extent of the burns, the nurse should not treat the
burn. Scald burns are not at high risk for infection
and do not need to be cleaned, covered, or treated
,with antibiotic cream at this time.
-3 . During the emergent (resuscitative) phase of
burn injury, which of the following indicates that
the client is requiring additional volume with fluid
resuscitation?
• 1. Serum creatinine level of 2.5 mg/dL.
• 2. Little fluctuation in daily weight.
• 3. Hourly urine output of 60 mL.
• 4. Serum albumin level of 3.8. - =3 . 1. Fluid
shifting into the interstitial space
causes intravascular volume depletion and
decreased perfusion to the kidneys. This would
result in an increase in serum creatinine. Urine out
put should be frequently monitored and adequately
maintained with intravenous fluid resuscitation that
would be increased when a drop in urine output
occurs. Urine output should be at least 30 mL/hour.
Fluid replacement is based on the Parkland or
Brooke formula and also the client's response by
monitoring urine output, vital signs, and CVP read
ings. Daily weight is important to monitor for fluid
status. Little fluctuation in weight suggests that
, there is no fluid retention and the intake is equal to
output. Exudative loss of albumin occurs in burns
causing a decrease in colloid osmotic pressure.
The
normal serum albumin is 3.5 to 5 gm/dL.
-4 . A client is admitted to the hospital after
sustaining burns to the chest, abdomen, right arm,
and right leg. The shaded areas in the illustration
indicate the burned areas on the client's body.
Using
the "rule of nines," the nurse would determine that
about what percentage of the client's body surface
has been burned?
• 1. 18%.
• 2. 27%.
• 3. 45%.
• 4. 64%. - =4 . 3. According to the rule of nines,
this cli
ent has sustained burns on about 45% of the body
surface. The right arm is calculated as being 9%,
the
right leg is 18%, and the anterior trunk is 18%, for a
total of 45%.
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