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NP2 Exam 3

Terms in this set (70)

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm?
A) Superficial partial-thickness
B) Deep partial-thickness
C) Full partial-thickness
D) Full-thickness
D) Full-thickness
The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care?
A) Emergent
B) Immediate resuscitative
C) Acute
D) Rehabilitation
C acute
3. A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what?
A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis
C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis
D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
A
4. A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?
A) Silver sulfadiazine 1% (Silvadene) water-soluble cream
B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution
D) Acticoat
B
5. An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn?
A) Apply ice to the site of the burn for 5 to 10 minutes.
B) Wrap the patients affected extremity in ice until help arrives.
C) Apply an oil-based substance or butter to the burned area until help arrives.
D) Wrap cool towels around the affected extremity intermittently.
D
6. An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
A) The length of time since the burn
B) The location of burned skin surfaces
C) The source of the burn
D) The total body surface area (TBSA) affected by the burn
D
7. A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?
A) 2 days B) 3 days C) 5 days D) 1 week
A
8. A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
A) Early enteral feeding
B) Administration of prophylactic antibiotics
C) Bowel cleansing procedures
D) Administration of stool softeners
A
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care?
A) Fluid status
B) Risk of infection
C) Nutritional status
D) Psychosocial coping
A
10. The nurse is preparing the patient for mechanical dbridement and informs the patient that this will involve which of the following procedures?
A) A spontaneous separation of dead tissue from the viable tissue
B) Removal of eschar until the point of pain and bleeding occurs
C) Shaving of burned skin layers until bleeding, viable tissue is revealed
D) Early closure of the wound
B
11. A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurses most appropriate intervention?
A) Reinforce the Biobrane dressing with another piece of Biobrane.
B) Remove the Biobrane dressing and apply a new dressing.
C) Trim away the separated Biobrane.
D) Notify the physician for further emergency-related orders.
C
An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?
A) The causative agent
B) The patients preinjury health status
C) The patients prognosis for recovery
D) The circumstances of the accident
A
13. A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
A) Activity Intolerance
B) Anxiety
C) Ineffective Coping
D) Acute Pain
D
14. A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel.
B) Apply butter to the area that is burned.
C) Immerse the child in a cool bath.
D) Avoid touching the burned area under any circumstances.
C
5. A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
A) 4 to 6 hours a day for 6 months
B) During waking hours for 2 to 3 months after the injury
C) Continuously
D) At night while sleeping for a year after the injury
C
A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation?
A) Pain B) Fluid balance C) Anxiety and fear D) Airway management
D
A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? A) 13% B) 25% C) 9% D) 18%
D
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A) Sodium deficit
B) Decreased prothrombin time (PT)
C) Potassium deficit
D) Decreased hematocrit
A
A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?
A) To prevent neuropathies
B) To prevent wound breakdown
C) To prevent contractures
D) To prevent heterotopic ossification
C
A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response? A) Perform mechanical dbridement to remove the exudate and prevent further infection.
B) Inform the primary care provider promptly because the graft may need to be removed.
C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing.
D) Document this finding as an expected phase of graft healing.
B
21. A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member? A) Hes on a calorie-restricted diet in order to divert energy to wound healing. B) His body has consumed his fat deposits for fuel because his calorie intake is lower than normal. C) He actually hasnt lost weight. Instead, theres been a change in the distribution of his body fat. D) He lost many fluids while he was being treated in the emergency phase of burn care.
B
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications?
A) A 4-year-old scald victim burned over 24% of the body
B) A 27-year-old male burned over 36% of his body in a car accident
C) A 39-year-old female patient burned over 18% of her body
D) A 60-year-old male burned over 16% of his body in a brush fire
A
23. A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what?
A) Hemodynamic instability B) Gastrointestinal hypermotility C) Respiratory arrest D) Hypokalemia
A
4. A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock?
A) Confusion
B) High fever
C) Decreased blood pressure
D) Sudden agitation
C
25. An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patients body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?
A) Administer IV fluids
B) Administer broad-spectrum antibiotics
C) Administer IV potassium chloride
D) Administer packed red blood cells
A
26. A patients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A) 0.45% NaCl with 20 mEq/L KCl
B) 0.45% NaCl with 40 mEq/L KCl
C) Normal saline
D) Lactated Ringers
D
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia
B) Referred pain
C) Cellulitis
D) Venous thromboembolism (VTE)
A. as edema increases, pressure on blood vessels ad nerves cause obstruction of blood flow/ ischemia.
A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?
A) Obtain an order to reduce the rate of the patients IV fluid infusion.
B) Report the patients early signs of acute kidney injury (AKI).
C) Recognize that the patient is experiencing an expected onset of diuresis.
D) Administer sodium chloride as ordered to compensate for this fluid loss.
C
9. A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort?
A) Education about home safety
B) Education about safe storage of chemicals
C) Education about workplace health threats
D) Education about safe driving
A
A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following?
A) Assess the patient for signs of electrolyte imbalances.
B) Administer fluids as ordered.
C) Assess the risk for injury recurrence.
D) Assess the patients psychosocial state.
D
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the patient to keep the wound site in a dependent position.
B) Administer PRN analgesia as ordered.
C) Assess the patients peripheral pulses distal to the dressing.
D) Assist with passive range of motion exercises to set the new dressing.
C
A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?
A) Maintenance of bed rest to aid healing
B) Choosing appropriate splints and functional devices
C) Administration of beta adrenergic blockers
D) Prevention of venous thromboembolism
D
3. A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.
A) Promote truthful communication.
B) Avoid asking the patient to make decisions.
C) Teach the patient coping strategies.
D) Administer benzodiazepines as ordered.
E) Provide positive reinforcement
A C E
A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?
A) Monitoring fluid and electrolyte imbalances
B) Providing education to the patient and family
C) Treating infection
D) Promoting thermoregulation
B
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?
A) Thats something that you and your doctor will likely talk about after your scars mature.
B) That is something for you to talk to your doctor about because its not a nursing responsibility.
C) I know this is really important to you, but you have to realize that no one can make you look like you used to.
D) Unfortunately, its likely that you will have most of these scars for the rest of your life.
A
A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patients needs?
A) A patient-controlled analgesia (PCA) system
B) Oral opioids supplemented by NSAIDs
C) Distraction and relaxation techniques supplemented by NSAIDs
D) A combination of benzodiazepines and topical anesthetics
A
37. The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk?
A) Apply skin emollients as ordered after granulation has occurred.
B) Keep injured areas immobilized whenever possible to promote healing.
C) Administer oral or IV corticosteroids as ordered.
D) Encourage physical activity and range of motion exercises.
D
38. While performing a patients ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patients behavior?
A) The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior.
B) The patient may be experiencing neurologic or psychiatric complications of his injuries.
C) The patient may be experiencing inconsistencies in the care that he is being provided.
D) The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.
D
9. A home care nurse is performing a visit to a patients home to perform wound care following the patients hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication?
A) Psychosis
B) Post-traumatic stress disorder
C) Delirium
D) Vascular dementia
B
A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?
A) Apply the new ointment without disturbing the existing layer of ointment.
B) Apply the ointment using a sterile tongue depressor.
C) Apply a layer of ointment approximately 1/16 inch thick.
D) Gently irrigate the wound bed after applying the antibiotic ointment.
C
The nurse is conducting wellness seminars in the community. One health promotion activity the nurse could advise to reduce the chances of developing cataracts is to
A. take a lot of Vit A and E
B. limit the amount of alcohol
C. drink plenty of water
D. wear sunglasses when outside
D
The client has experienced an episode of Myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:

A. respiratory infection
◦ B. too little exercise
◦ C. additional doses of medication
◦ D. pregnancy
E. missed doses of medications
ADE
the nurse determines that the fluid replacement for a patient with major burns is adequate based on the finding of:
A. total fluid intake equal to urinary output
B. urinary output 0.5mL/kg/hr
C. daily weight unchanged from admission
D. BP of 90/58
B
the nurse is reviewing the physician's orders for a client with Meniere's disease. Which diet most likely would be prescribed for the client?
A. low fat
B. low sodium
C. low cholesterol
D. low carbohydrate
B. low sodium
the nurse is conducting a wellness seminar on healthy hearing through the life span and would suggest which of the following activities as PRIMARY prevention for hearing loss? select all
A. avoid inserting hard objects into ear
B. care for your hearing aids according to the manufacturers' directions
C. see your dr right away for symptoms of ear infection
D. wear ear protection when you attend a concert
E. use caution taking medications that can cause hearing loss
A D E
a patient with documented history of seizure disorder experiences a tonic clonic seizure. what nursing action is most appropriate?
A. restrain the pt to prevent injury
B. loosen the pt restrictive clothing
C. open the pt jaws to insert an oral airway
D. plate pt in high fowler's position
B- loosen restrictive clothing
a patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. what aspect of the patient's current health status is most likely to have precipitated this event?
A. the pt urinary catheter became occluded
B.. the patient received a blood transfusion
C. the pt analgesia regimen was recently changed
D. the pt was not repositioned
A- urinary catheter
a 25 year old male patient is admitted to the burn unit after experiencing burns to his bilateral lower extremities. the wounds on high thighs are dry, black, painless. how would the nurse classify these burns?
A. deep partial thickness
B. partial thickness
C. full thickness
D. superficial thickness
C. full thickness
the nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. which of the following measures would the nurse avoid in planning for the client's safety?
A. placing an airway, oxygen, and suction equipment at bedside
B. padding the side rails of the bed
C. putting a padded tongue blade at head of bed
C
A patient presents 4 hours after a severe burn injury. which of the following is the initial priority assessment>
A. assess for grip strength
B. inspect location, extent, shape of burn injuries
C. asssess for infection
D. assess for signs of smoke inhalation and burns to the face and neck
D- smoke inhalation
following a debulking procedure with open craniotomy for a pt with a brain tumor, the nurse would anticipate administering which of the following medications? select all
A. steroids
B. short term antibiotics
C. pain management
D. antiepileptics
E. loop diuretics
ABCD
on initial assessment of a pt hospitalized following an ischemic stroke, the nurse finds the pts BP to be 170/90mmHg. which of the following orders by the health care provider should the nurse question?
A. keep HOB elevated 30 degrees
B. administer tissue plasminogen activator tPA per protocal
C. titrate labetolol Normodyne drip to keep BP less than 140/90.
C
the nurse is caring for a client following a crainotomy for removal of an acoustic neuroma. asessment of which of the following cranial nerves would identify complication specifically associated with this surgery?
A. cranial nerve 3- oculomotor
B. Cranial nerve 7- facial
C. cranial nerve 1- olfactory
D. cranial nerve 4- trochlear
B- facial nerve 7
A client experiences burns on the locations: whole head, chest, abdomen. What is estimated body surface burned?
27%
a 200lb client is receiving fluid replacement in the ED after 35% of clients body was burned. the nurse would anticipate the 24 hours total fluid resuscitation to be _______mL.
6364
the nurse is evaluating the status of a client who had a craniotomy 3 days ago. the nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits which of the following signs?
A. glascow coma scale of 15.
B. absense of nuchal rigidity
C. negative kernig's sign
D. positive brudzinski's sign
D. Brudzinski
the nurse caring for a pt in persistent vegetative state is regularly assessed for potential complications. complications of neurologic dysfunction for which the nurse should assess include which of the following? select all
a. pressure ulcers
b. pneumonia
C. hemorrhage
D. venous thromboemboilsm
E. contractures
ABDE
a hospitalized patient with myasthenia gravis MG has a nursing diagnosis of imbalanced nutrition less than body requirements related to impaired swallowing. to promote nutrition, the nurse suggest that before meals, the pt should avoid:
A. talking on the phone
B. ambulating in the halls
C. typing on computer
D. watching TV
A. talking on phone-- same muscles
a client receives a dose of edrophonium tensilon intravenously. the client shows improvement in muscle strength for a short period of time following the infusion. the nurse interprets that this finding is diagnostically consistent with which of the following disease processes?
A. trigeminal neuralgia
B. multiple slerosis
C. myasthena gravis
C- MG
a nurse is caring for a client with severe burns. the client complains of abdominal pain and begins vomiting blood. the nurse anticipates diagnostic testing to determine if the client has developed
A. H. pylori infection
B. a curling's ulcer
C. chronic gastritis
D. pyloric stenosis
B- curling's ulcer
the nurse is assessing the client who is experiencing seizure activity. the nurse understand that it is unnecessary to determine information about which of the following items as part of routine assessment of seizures?
A. seizure progression and type of movements
B. changes in pupil size or deviation
C. duration of seizure
D. what the client ate in 2 hours preceding seizure activity
D- what the client ate
the nurse is providing health education to a pt who has a C6 spinal cord injury. the pt asks why autonomic dysreflexia is considered an emergency. what would the nurse best answer?
the sudden increase in BP can raise ICP or rupture a cerebral blood vessel
when caring for a pt who has had a stroke, a priority is reduction of ICP. what pt position is most consistent with this goal?
1. head midline, bed elevated 30 degreed
2. head turned slightly to the right, high fowlers
3. position changes every 15 min while away
head midline, bed 30 degrees
carbidopa-levodopa (Sinemet) is prescribed for the client with Parkinson's disease. the nurse monitors client for adverse rxs. which of the following would indicate the client is experiencing an adverse reaction?
A. pruritus
B. tachycardia
C. impaired voluntary movements
D. hypertension
C- impaired voluntary movements
The client with Parkinson's disease has a nursing diagnosis of Risk for Falls related to an abnormal gait documented in the nursing care plan. The nurse assesses the client expecting to observe which type of gait?
A. unsteady and staggering
B. accelerating with walking on toes
C. shuffling and propulsive
C- shuffling and propulsive
The patient diagnosed with atrial fibrillation has experienced a transient ischemic attack. Which medication would the nurse anticipate being ordered for the patient on discharge?
A. a corticosteroid med
B. a thrombolytic med
C. an oral anticoagulant
C- an oral anticoagulant
the current phase of a patient's treatment for a burn injury prioritizes prevention of scars, psychological counseling, and cosmetic reconstruction. based on these care priorities, the patient is in what phase of burn care?
A. rehab
B. reconstructive
C. emergent
D. acute
A- rehab

emergent focuses on airway, hypovolemic shock and compartment.
acute focuses on airway, infection, pain, wound care
a patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure ICP. what nursing intervention would be most appropriate for the patient?
A. absolute bed rest in a quiet non stimulating environment
B. early initiation of physical therapy
C. Range of motion exercises to prevent contractures
A- absolute bed rest in a quiet non stimulating environment
The patient diagnosed with septic meningitis is admitted to the medical floor at noon. which health care provider's order would have highest priority?
A. provide quiet calm and dark room
B. obtain the patient's lunch tray
C. administer intravenous antibiotics
C- administer IV antibiotics
the current phase
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