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UNIT 6- IGGY STUDY GUIDE and Lacharity
Terms in this set (13)
What priority complication would the nurse suspect when assessing a client with an electrical burn that has an entrance wound on the right shoulder and an exit wound through the left side ribs?
A. Kidney failure
B. Cardiac dysrhythmias
C. Gastrointestinal ileus
D. Fractured ribs
Which assessment findings would the emergency department (ED) nurse expect when a client has a smoke-related inhalation injury? Select all that apply.
A. Soot around the nose or mouth
B. Singed nasal hairs
C. Hoarseness of speech
D. Shortness of breath
E. Cherry red skin
What is the priority focus of prehospital care for a client with a chemical injury burn?
B. Fluid balance
C. Airway control
D. Preventing infection
Which teaching strategies would the nurse include when instructing clients about how to prevent burn injuries? Select all that apply.
A. Hot water heaters should be set below 150°F (65.5°C).
B. Never add a flammable substance to an open flame.
C. Use sunscreen and protective clothes to avoid sunburn.
D. Avoid smoking when drinking alcohol or taking drugs that induce sleep.
E. When space heaters are used, keep flammable objects away from them.
F. If using home oxygen, do not smoke in the room where oxygen is in use.
What would be the nurse's best action when a client with a burn injury develops a brassy cough, increased difficulty swallowing, and progressive hoarseness?
A. Place the client on continuous pulse oximetry.
B. Instruct the AP to check vital signs every 30 minutes.
C. Activate the Rapid Response Team.
D. Establish a second IV access.
Which is the best action for the nurse to take prior to changing the dressing of a client with a burn injury?
A. Allow the client to rest and nap for an hour.
B. Give pain medication 30 minutes prior to dressing change.
C. Instruct the AP to give the client a complete bath.
D. Leave the wound open to air for 30 minutes.
Which are priorities of care when providing care for a client with a burn injury during the emergent phase? Select all that apply.
A. Securing the airway
B. Maintaining nutrition status
C. Supporting circulation and perfusion
D. Maintaining body temperature
E. Keeping client comfortable with analgesics
F. Psychosocial adjustment
Which factors increase the risk of complications from a burn injury in an older adult client? Select all that apply.
A. Slower healing time
B. Thinner skin
C. Increased inflammatory response
D. Increased pulmonary compliance
E. Medical conditions such as diabetes
F. Increased immune response
You have just received a change-of-shift report for the burn unit. Which client should you assess first?
A. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain
B. Client who has just arrived from the emergency department with facial burns sustained in a house fire
C. Client who has just been transferred from PACU after having skin grafts applied to the anterior chest
D. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching
You are performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care plan in the order in which each should be accomplished.
A. Apply silver sulfadiazine (Silvadene) ointment
B. Obtain specimens for aerobic and anaerobic wound cultures
C. Administer morphine sulfate 10mg IV
D. Debride the wound of eschar using gauze sponges
E. Cover the wound with a sterile gauze dressing
C, D, B, A, E
You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit?
A. 23yo who has just been admitted with burns over 30% of the body after a warehouse fire
B. 36yo who requires discharge teaching about nutrition and wound care after having skin grafts
C. 45yo with infected partial-thickness back and chest burns who has a dressing change scheduled
D. 57yo with full-thickness burns on both arms who needs assistance in positioning hand splints
A client who has extensive blister injuries the back and both legs caused by exposure to toxic chemicals at work is admitted to the ED. Which ordered intervention will you implement first?
A. Infuse Lactated Ringers solution at 250mL/hr
B. Rinse the back and legs with 4L of sterile normal saline
C. Obtain blood for a complete blood count and electrolyte levels
D. Document the percentage of total body surface area burned
You have just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention?
A. 22yo admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left
B. 34yo who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (on a scale of 0-10)
C. 45yo with partial-thickness leg burns who has a temperature of 102.6 and a blood pressure of 98/46
D. 57yo who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1
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