Upgrade to remove ads
Only $35.99/year

exam 4 - 3664

Terms in this set (63)

After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take?

a. Teach the patient about normal AVG function.

b. Remind the patient to take a daily low-dose aspirin tablet.

c. Report the patients symptoms to the health care provider.

d. Elevate the patients arm on pillows to above the heart level.
c. Report the patients symptoms to the health care provider.

The patients complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion.
When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of

a. persistent skin tenting
b. rapid, deep respirations
c. bounding peripheral pulses
d. hot, flushed face and neck
b. rapid, deep respirations

Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Patient is likely to have fluid retention, so poor skin turgor is not a finding.
The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be

a. augmenting fluid volume.

b. maintaining cardiac output.

c. diluting nephrotoxic substances.

d. preventing systemic hypertension.
b. maintaining cardiac output.

The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patients heart failure is causing AKI, the care will be directed toward treatment of the heart failure.
A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?

a. urine volume
b. calcium level
c. cardiac rhythm
d. neurologic status
c. cardiac rhythm

The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia.
A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question?

a. NPO for 6 hours before procedure

b. Ibuprofen (Advil) 400 mg PO PRN for pain

c. Dulcolax suppository 4 hours before procedure

d. Normal saline 500 mL IV infused before procedure
b. Ibuprofen (Advil) 400 mg PO PRN for pain

The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided.
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function?

a. Continue to monitor the urine output.

b. Monitor for increased white blood cells (WBCs).

c. Assess that blisters and edema have subsided.

d. Prepare the patient for discharge from the burn unit.
ANS: A

The patients urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity.
Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?

a. blood pressure
b. phosphate level
c. neurologic status
d. creatinine clearance
ANS: B

Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD.
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the

a. bowel sounds.

b. blood glucose.

c. blood urea nitrogen (BUN).

d. level of consciousness (LOC).
ANS: A

Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur.
Which menu choice by the patient who is receiving hemodialysis indicates that the nurses teaching has been successful?

a. Split-pea soup, English muffin, and nonfat milk

b. Oatmeal with cream, half a banana, and herbal tea

c. Poached eggs, whole-wheat toast, and apple juice

d. Cheese sandwich, tomato soup, and cranberry juice
ANS: C

Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.
Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for

a. potassium level.

b. total cholesterol.

c. serum phosphate.

d. serum creatinine.
c. serum phosphate.

If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered.
A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?

a. Urine volume

b. Creatinine level

c. Glomerular filtration rate (GFR)

d. Blood urea nitrogen (BUN) level
ANS: C

GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake.
A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft?

a. A fistula is much less likely to clot.

b. A fistula increases patient mobility.

c. A fistula can accommodate larger needles.

d. A fistula can be used sooner after surgery.
a. A fistula is much less likely to clot.

Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis.
When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?

a. Auscultate for a bruit at the fistula site.

b. Assess the quality of the left radial pulse.

c. Compare blood pressures in the left and right arms.

d. Irrigate the fistula site with saline every 8 to 12 hours.
a. Auscultate for a bruit at the fistula site.

The presence of a thrill and bruit indicates adequate blood flow through the fistula
A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching?

a. Increased calories are needed because glucose is lost during hemodialysis.

b. Unlimited fluids are allowed because retained fluid is removed during dialysis.

c. More protein is allowed because urea and creatinine are removed by dialysis.

d. Dietary potassium is not restricted because the level is normalized by dialysis.
c. More protein is allowed because urea and creatinine are removed by dialysis.

Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged.
Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?

a. The patient leaves the catheter exit site without a dressing.

b. The patient plans 30 to 60 minutes for a dialysate exchange.

c. The patient cleans the catheter while taking a bath each day.

d. The patient slows the inflow rate when experiencing abdominal pain.
ANS: C

Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side
Which information in a patients history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation?

a. The patient has type 1 diabetes.

b. The patient has metastatic lung cancer.

c. The patient has a history of chronic hepatitis C infection.

d. The patient is infected with the human immunodeficiency virus.
b. The patient has metastatic lung cancer.
The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?

a. Multivitamin with iron

b. Magnesium hydroxide

c. Acetaminophen (Tylenol)

d. Calcium phosphate (PhosLo)
ANS: B

Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium
Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patients

a. glucose.

b. potassium.

c. creatinine.

d. phosphate.
ANS: B

Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention.
A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patients

a. blood glucose.

b. urine osmolality.

c. serum creatinine.

d. serum potassium.
ANS: C

When a patient at risk for chronic kidney disease (CKD) receives a potentially nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels
A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication?

a. Creatinine 1.6 mg/dL

b. Oxygen saturation 89%

c. Hemoglobin level 13 g/dL

d. Blood pressure 98/56 mm Hg
c. Hemoglobin level 13 g/dL

High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose.
Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein?

a. Start continuous pulse oximetry.

b. Restrict physical activity to bed rest.

c. Restrict the patients oral protein intake.

d. Discontinue the urethral retention catheter.
ANS: B

The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein.
A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider?

a. Serum creatinine level 2.1 mg/dL

b. Serum potassium level 6.5 mEq/L

c. White blood cell count 11,500/L

d. Blood urea nitrogen (BUN) 56 mg/dL
ANS: B

The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately.
A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

a. Insert urethral catheter.

b. Obtain renal ultrasound.

c. Draw a complete blood count.

d.Infuse normal saline at 50 mL/hour.
ANS: A

The patients elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient.
A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?

a. The creatinine level is 3.0 mg/dL.

b. Urine output over an 8-hour period is 2500 mL.

c. The blood urea nitrogen (BUN) level is 67 mg/dL.

d. The glomerular filtration rate is <30 mL/min/1.73m2.
ANS: B

The high urine output indicates a need to increase fluid intake to prevent hypovolemia.
A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first?

a. Notify the patients health care provider.

b. Document the QRS interval measurement.

c. Check the medical record for most recent potassium level.

d. Check the chart for the patients current creatinine level.
ANS: C

The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patients health care provider.
A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first?

a. Insert a urinary retention catheter.

b. Place the patient on a cardiac monitor.

c. Administer epoetin alfa (Epogen, Procrit).

d. Give sodium polystyrene sulfonate (Kayexalate).
ANS: B

Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm.
A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician?

a. Teach the patient about fluid restrictions.

b. Check blood pressure before starting dialysis.

c. Assess for causes of an increase in predialysis weight.

d. Determine the ultrafiltration rate for the hemodialysis.
ANS: B

Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.
A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider?

a. The patient has an outflow volume of 1800 mL.

b. The patients peritoneal effluent appears cloudy.

c. The patient has abdominal pain during the inflow phase.

d. The patients abdomen appears bloated after the inflow.
b. The patients peritoneal effluent appears cloudy.

Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started.
During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first?

a. Slow down the rate of dialysis.

b. Check patients blood pressure (BP).

c. Review the hematocrit (Hct) level.

d. Give prescribed PRN antiemetic drugs.
ANS: B

The patients complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP.
A patient complains of leg cramps during hemodialysis. The nurse should first

a. massage the patients legs.

b. reposition the patient supine.

c. give acetaminophen (Tylenol).

d. infuse a bolus of normal saline.
ANS: D

Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline.
A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, Do you think I should go on dialysis? Which initial response by the nurse is best?

a. It depends on which type of dialysis you are considering.

b. Tell me more about what you are thinking regarding dialysis.

c. You are the only one who can make the decision about dialysis.

d. Many people your age use dialysis and have a good quality of life.
ANS: B

The nurse should initially clarify the patients concerns and questions about dialysis.
After receiving change-of-shift report, which patient should the nurse assess first?

a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange

b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level

c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L

d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min
ANS: D

The patient who is tachycardic after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications.
Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)?

a. Avoid commercial salt substitutes.

b. Drink 1500 to 2000 mL of fluids daily.

c. Take phosphate-binders with each meal.

d. Choose high-protein foods for most meals.

e. Have several servings of dairy products daily.
A, C, D

Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is limited in patients requiring dialysis. Dairy products are high in phosphate and usually are limited.
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?

a. First-degree skin destruction

b. Full-thickness skin destruction

c. Deep partial-thickness skin destruction

d. Superficial partial-thickness skin destruction
ANS: B

With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now?

a. Monitor urine output every 4 hours.

b. Continue to monitor the laboratory results.

c. Increase the rate of the ordered IV solution.

d. Type and crossmatch for a blood transfusion.
ANS: C

The patients laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased.
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

a. Encourage the patient to cough and auscultate the lungs again.

b. Notify the health care provider and prepare for endotracheal intubation.

c. Document the results and continue to monitor the patients respiratory rate.

d. Reposition the patient in high-Fowlers position and reassess breath sounds.
b. Notify the health care provider and prepare for endotracheal intubation.

The patients history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly.
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?

a. 350 mL/hour

b. 523 mL/hour

c. 938 mL/hour

d. 1250 mL/hour
ANS: C

Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

a. Check skin turgor.

b. Monitor daily weight.

c. Assess mucous membranes.

d. Measure hourly urine output.
ANS: D

When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour.
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?

a. Insert a feeding tube and initiate enteral feedings.

b. Infuse total parenteral nutrition via a central catheter.

c. Encourage an oral intake of at least 5000 kcal per day.

d. Administer multiple vitamins and minerals in the IV solution.
ANS: A

Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption.
While the patients full thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination?

a. Use sterile gloves when removing old dressings.

b. Wear gowns, caps, masks, and gloves during all care of the patient.

c. Administer IV antibiotics to prevent bacterial colonization of wounds.

d. Turn the room temperature up to at least 70 F (20 C) during dressing changes.
ANS: B

Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85 F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?

a. Place the right arm and hand flexed in a position of comfort.

b. Elevate the right arm and hand on pillows and extend the fingers.

c. Assist the patient to a supine position with a small pillow under the head.

d. Position the patient in a side-lying position with rolled towel under the neck.
ANS: B

The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures.
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take?

a. Notify the health care provider.

b. Monitor the pulses every 2 hours.

c. Elevate both legs above heart level with pillows.

d. Encourage the patient to flex and extend the toes on both feet.
ANS: A

The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy.
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication?

a. Bowel sounds

b. Stool frequency

c. Abdominal distention

d. Stools for occult blood
ANS: D

H2 blockers and proton pump inhibitors are given to prevent Curlings ulcer in the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite.
The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement?

a. Ketorolac (Toradol)

b. Lorazepam (Ativan)

c. Gabapentin (Neurontin)

d. Hydromorphone (Dilaudid)
d. Hydromorphone (Dilaudid)

Opioid pain medications are the best choice for pain control.
A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving?

a. Im glad the scars are only temporary.

b. I will avoid using a pillow, so my neck will be OK.

c. I bet my boyfriend wont even want to look at me anymore.

d. Do you think dark beige makeup foundation would cover this scar on my cheek?
ANS: D

The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving.
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function?

a. Continue to monitor the urine output.

b. Monitor for increased white blood cells (WBCs).

c. Assess that blisters and edema have subsided.

d. Prepare the patient for discharge from the burn unit.
ANS: A

The patients urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity.
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient?

a. Bananas

b. Orange gelatin

c. Vanilla milkshake

d. Whole grain bagel
ANS: C

A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients.
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

a. Oral temperature

b. Peripheral pulses

c. Extremity movement

d. Pupil reaction to light
ANS: C

All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data.
An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take?

a. Remove nonadherent clothing and watch.

b. Apply an alkaline solution to the affected area.

c. Place cool compresses on the area of exposure.

d. Cover the affected area with dry, sterile dressings.
ANS: A

With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed).
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?

a. Stay at the bedside and reassure the patient.

b. Administer the ordered morphine sulfate IV.

c. Assess orientation and level of consciousness.

d. Use pulse oximetry to check the oxygen saturation.
d. Use pulse oximetry to check the oxygen saturation.

Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first.
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

a. Auscultate the patients lung sounds.

b. Determine the extent and depth of the burns.

c. Infuse the ordered lactated Ringers solution.

d. Administer the ordered hydromorphone (Dilaudid).
ANS: A

A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority.
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

a. Assess oral temperature.

b. Check a potassium level.

c. Place on cardiac monitor.

d. Assess for pain at contact points.
ANS: C

After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor.
Eight hours after a thermal burn covering 50% of a patients total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider?

a. Blood pressure is 95/48 per arterial line.

b. Serous exudate is leaking from the burns.

c. Cardiac monitor shows a pulse rate of 108.

d. Urine output is 20 mL per hour for the past 2 hours.
ANS: D

The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock.
Which patient should the nurse assess first?

a. A patient with smoke inhalation who has wheezes and altered mental status

b. A patient with full-thickness leg burns who has a dressing change scheduled

c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
ANS: A

This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine the need for oxygen or intubation.
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patients skin color is bright red. Which action should the nurse take first?

a. Insert two large-bore IV lines.

b. Check the patients orientation.

c. Assess for singed nasal hair and dark oral mucous membranes.

d. Place the patient on 100% oxygen using a non-rebreather mask.
d. Place the patient on 100% oxygen using a non-rebreather mask.

The patients history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%.
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?

a. Hematocrit 53%

b. Serum sodium 147 mEq/L

c. Serum potassium 6.1 mEq/L

d. Blood urea nitrogen 37 mg/dL
ANS: C

Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level.
The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse?

a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound.

b. The new nurse obtains burn cultures when the patient has a temperature of 95.2 F (35.1 C).

c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change.

d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patients serum glucose is elevated.
ANS: A

Sterile gloves should be worn when applying medications or dressings to a burn.
Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

a. Obtain the blood pressure.

b. Stabilize the cervical spine.

c. Assess for the contact points.

d. Check alertness and orientation.
ANS: B

Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management.
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?

a. Keep the right arm in a position of comfort.

b. Avoid the use of sustained-release narcotics.

c. Teach about the purpose of tetanus immunization.

d. Apply water-based cream to burned areas frequently.
ANS: D

Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort.
A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, Im sorry that Im still alive. My life will never be normal again. Which response by the nurse is best?

a. Most people recover after a burn and feel satisfied with their lives.

b. Its true that your life may be different. What concerns you the most?

c. It is really too early to know how much your life will be changed by the burn.

d. Why do you feel that way? You will be able to adapt as your recovery progresses.
b. Its true that your life may be different. What concerns you the most?
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringers solution that the nurse will administer during the first 8 hours?
ANS:

600 mL

The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4x80x30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patients total body surface area (TBSA) has been injured?
ANS:

27%

When using the rule of nines, the anterior trunk is considered to cover 18% of the patients body and each arm is 9%.
In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patients chest? (Put a comma and a space between each answer choice [A, B, C, D, E].)

a. Apply sterile gauze dressing.

b. Document wound appearance.

c. Apply silver sulfadiazine cream.

d. Administer IV fentanyl (Sublimaze).

e. Clean wound with saline-soaked gauze.
ANS:

D, E, C, A, B

Because partial-thickness burns are very painful, the nurses first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.
Students also viewed