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