Chapter 17 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 17

Question 1

Type: MCMA

The nurse providing an overview of burns to a community group is teaching the causes for thermal burns. These causes include:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Contact with steam

2. Exposure to hot liquids

3. Being splashed with drain cleaner

4. Stepping on hot charcoal

5. Friction injuries

Correct Answer: 1,2,4,5

Rationale 1: Thermal burns include scald injuries from exposure to steam.

Rationale 2: Thermal burns include scald injuries from exposure to hot liquids.

Rationale 3: Drain cleaner represents a chemical source.

Rationale 4: Thermal burns include fire/flame injuries.

Rationale 5: Thermal burns include contact/friction injuries.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 17-1: Explain the common etiologies of burn injuries.

Question 2

Type: MCSA

The nurse is explaining to the granddaughter of an 85-year-old patient that older persons are at greater risk for scalding by hot water due to:

1. This age groups adversity to taking showers

2. An inclination to test the waters temperature

3. Overall slower reaction time

4. Loss of elasticity of skin tissue

Correct Answer: 3

Rationale 1: It is easier for older people to take a shower because they do not have to risk slipping and falling while getting in and out of a bathtub.

Rationale 2: Older people can have a decrease in memory and forget to test the water temperature.

Rationale 3: Older and disabled individuals are at risk for scalding by hot bath water due to impaired sensation, slower reaction times, and decreased mobility.

Rationale 4: Loss of skin elasticity is not a risk factor but could affect the severity.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-1: Explain the common etiologies of burn injuries.

Question 3

Type: MCSA

A patient rescued from a small house fire is brought to the emergency department. There is no burn injury to the skin, however laboratory results show a CO level of 22%. Which intervention would the nurse expect to implement?

1. Administer high-flow nebulizer treatment.

2. Infuse a fluid bolus of lactated Ringers solution.

3. Begin a sodium bicarbonate drip.

4. Give 100% oxygen by mask.

Correct Answer: 4

Rationale 1: This treatment will only open airways but not displace the carbon monoxide.

Rationale 2: This treatment would be used for fluid resuscitation, not gas exchange treatment.

Rationale 3: A bicarbonate drip is only used for severe metabolic acidosis that is not responsive to other treatment.

Rationale 4: Carbon monoxide has a stronger affinity for hemoglobin than oxygen does so it displaces oxygen as it binds with the hemoglobin. This impairs oxygen transport and tissue perfusion. The treatment is high-flow 100% oxygen.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-6: Explain priorities in the care of the patient with major burns during the resuscitation phase.

Question 4

Type: MCMA

The critical care nurse is aware that the depth of burn injury is determined by the depth of tissue destruction and which other factors?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Duration of the burn exposure

2. Additional chronic medical conditions

3. Skin thickness

4. The cause of the burn

5. Body part of the burn injury

Correct Answer: 1,3,4

Rationale 1: A number of factors contribute to burn depth including the duration of the burning agent.

Rationale 2: The presence of other medical conditions may affect healing but is not a factor in determining burn depth.

Rationale 3: A number of factors contribute to burn depth including the skin thickness.

Rationale 4: A number of factors contribute to burn depth including the etiology.

Rationale 5: Location of body part burned may affect healing but is not a factor in determining burn depth.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-2: Evaluate the severity of a burn injury.

Question 5

Type: MCSA

Which assessment finding by the nurse would be suggestive of a minor burn?

1. The involved skin is deep reddish-brown in color and edematous.

2. Blisters begin to form on the skin within the first hour of exposure.

3. The skin remains intact because only the epidermal layer is involved.

4. Scarring will be evident on the edges of the burn in a matter of hours.

Correct Answer: 3

Rationale 1: The color of a minor burn is not deep reddish-brown. The skin will be slightly edematous in a minor burn.

Rationale 2: Blisters will not form until after 24 hours, if at all.

Rationale 3: Superficial, or first-degree burns, involve only the epidermal layer of the skin, leaving the skin intact. The involved skin is pink to red in color and slightly edematous.

Rationale 4: These burns will heal without scarring in 3 to 6 days.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-2: Evaluate the severity of a burn injury.

Question 6

Type: MCSA

When assessing zone of coagulation of a third-degree burn injury, the nurse would be alert for:

1. The presence of pain

2. Brisk capillary refill

3. Surface of the wound that is dry and firm

4. A bright red wound color

Correct Answer: 3

Rationale 1: There is no pain sensation in this zone because the nerve endings have been destroyed.

Rationale 2: Capillary refill is minimal to nonexistent with a third-degree burn.

Rationale 3: The surface of a third-degree burn is dry, firm, and may have a leathery feel.

Rationale 4: The second-degree superficial burn wound is often bright red in color, but with a third-degree burn the color is dark. There may be a hard crust that forms over the necrotic tissue (eschar).

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-2: Evaluate the severity of a burn injury.

Question 7

Type: MCSA

A patient comes to the emergency department with thermal burns to the left arm and shoulder. Which finding requires immediate attention by the nurse?

1. Complaint of excessive thirst

2. Loss of range of motion to the affected side

3. Pain rating of 8 on a 1 to 10 scale

4. Presence of coughing and hoarseness

Correct Answer: 4

Rationale 1: Complaint of thirst would be expected due to dehydration.

Rationale 2: Limited range of motion to the affected side is an expected finding.

Rationale 3: A high pain rating is an expected finding.

Rationale 4: Immediate signs of inhalation injury are changes to the mucosal lining of the oropharynx and larynx, including the presence of soot, hoarseness, edema, or blisters. The ABCs of resuscitation should be followed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-2: Evaluate the severity of a burn injury.

Question 8

Type: MCSA

Which patient situation would present the greatest risk for an inhalation injury? The patient:

1. With a second-degree electrical burn of the hand

2. Trapped on an elevator during a fire in a building

3. With asthma who has extensive first-degree sunburn

4. With a scalding injury from liquid splashed on the legs

Correct Answer: 2

Rationale 1: There is no smoke inhalation associated with an electrical burn.

Rationale 2: Being trapped on an elevator during a fire in a building poses the greatest risk for an inhalation injury because of exposure to smoke or heat within an enclosed place.

Rationale 3: There is no smoke inhalation associated with sunburn.

Rationale 4: A scald injury is associated with hot water, not fire or smoke inhalation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-2: Evaluate the severity of a burn injury.

Question 9

Type: MCSA

A patient in ICU with a burn circling the left upper leg suddenly experiences excruciating pain, pallor in the lower extremity, and loss of pedal pulse. The nurse would immediately notify the physician because this patient might be developing:

1. Compartment syndrome

2. Inability to perform ADLs

3. Nosocomial infection

4. A deep vein thrombosis

Correct Answer: 1

Rationale 1: Circumferential extremity burns are at risk for developing compartment syndrome in which the pressure within the muscle compartments is greater than that within the microvasculature. These symptoms are characteristic of a loss of circulation due to compression of the blood vessels.

Rationale 2: The ability to perform ADLs would likely not differ based on the location of the burn.

Rationale 3: All hospitalized patients experiencing burns are at risk for nosocomial infections.

Rationale 4: The symptoms of a deep vein thrombosis are more likely to be swelling, warmth, and pain in the extremity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-4: Explain the changes within body systems that occur following a burn injury.

Question 10

Type: MCSA

What would the nurse teach a patient with a burn injury about skin changes that occur following a large burn?

1. Regulating body temperature returns with healing.

2. Healed burn areas are more susceptible to mechanical injury.

3. Sensory perception never returns once healing of a burn is complete.

4. Vitamin D from sun exposure facilitates the healing process.

Correct Answer: 2

Rationale 1: Patients with large burns are more susceptible to infection and have difficulty regulating body temperature even after the burn wound is healed.

Rationale 2: Healed burned areas are more susceptible to mechanical injury as a consequence of changes in the texture of the skin and decrease of sensory perception.

Rationale 3: Sensation will eventually return but it may be altered.

Rationale 4: Sun exposure should be avoided because burned areas are more susceptible to ultraviolet radiation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-4: Explain the changes within body systems that occur following a burn injury.

Question 11

Type: MCSA

An alert patient at the scene of an explosion has a respiratory rate of 24 breaths per minute, a faint stridor, and soot on the face. The patients heart rate is 120 beats per minute. Which action would be most appropriate to implement first?

1. Administering humidified oxygen

2. Placing on a cardiac monitor

3. Inserting a large-bore angiocatheter

4. Prophylactically intubating the patient

Correct Answer: 4

Rationale 1: Providing humidified oxygen would be appropriate after an airway is secured.

Rationale 2: Placing on a cardiac monitor would be appropriate after an airway is secured.

Rationale 3: Obtaining intravenous access would be appropriate after an airway is secured.

Rationale 4: This is the most appropriate first action because the first assessment of a burn patient, whether at the scene or in the emergency department, would be a primary trauma survey beginning with the ABCs (airway, breathing, circulation). In order to secure an airway, this patient may be prophylactically intubated because there are signs of progressing respiratory stress and airway edema related to the tachypnea, stridor, and presence of soot, which places the patient at increased risk for inhalation injury. Procuring a secure endotracheal tube is very important because it is very difficult to reintubate a burn patient due to severe airway edema and neck swelling.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5: Describe initial assessment and management of a patient with a burn injury.

Question 12

Type: MCSA

Following establishment of an airway, adequate breathing, and circulation, the nurse would focus next on which assessment following a burn injury?

1. Determining total body surface area of the burn

2. A quick check of neurologic status

3. Psychologic trauma resulting from the incident

4. Details of how the injury occurred

Correct Answer: 2

Rationale 1: The TBSA percentage and details of how the burn occurred would also be important assessments but are done after the ABCs are completed.

Rationale 2: Once the initial ABCs have been assessed, neurologic status should be examined. A burn patient should be awake and able to follow commands. Decreased neurologic status or unconsciousness may indicate anoxic injury or an additional neurologic injury.

Rationale 3: Physical needs and assessments must be completed prior to psychologic needs.

Rationale 4: This would be done after the airway has been secured.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5: Describe initial assessment and management of a patient with a burn injury.

Question 13

Type: MCSA

The burn unit nurse teaches a new staff nurse the priority nursing actions during the resuscitation phase of burn management. Which statement made by the inexperienced nurse indicates a need for further teaching?

1. We should promote an increased oral fluid intake.

2. A urinary catheter is usually inserted.

3. Ill get a nasogastric tube and suction equipment ready.

4. All patients should have a large-bore IV access if possible.

Correct Answer: 1

Rationale 1: We should promote an increased oral fluid intake is correct as a statement that requires further teaching. A nasogastric tube should be placed and suction applied to prevent aspiration; therefore, the patient will be NPO. This is also done to reduce the risk of the development of paralytic ileus.

Rationale 2: A urinary catheter should be placed prior to administering large boluses of fluids.

Rationale 3: This statement reflects an appropriate action and preparation.

Rationale 4: Patients with major burns entering this phase should have large-bore intravenous access for fluid administration.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 17-6: Explain priorities in the care of the patient with major burns during the resuscitation phase.

Question 14

Type: MCSA

A middle-aged male patient weighing 220 pounds incurred burns to 40% of the total body surface area. Using the Parkland formula, calculate his fluid resuscitation needs for the first 24 hours.

1. 3,520 mL

2. 35,200 mL

3. 1,600 mL

4. 16,000 mL

Correct Answer: 4

Rationale 1: Sixteen thousand milliliters is the correct amount of IV fluid for resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 2.2 = 100 kg) 4 mL 100 kg 40% = 16,000 mL.

Rationale 2: Sixteen thousand milliliters is the correct amount of IV fluid for resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 2.2 = 100 kg) 4 mL 100 kg 40% = 16,000 mL.

Rationale 3: Sixteen thousand milliliters is the correct amount of IV fluid for resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 2.2 = 100 kg) 4 mL 100 kg 40% = 16,000 mL.

Rationale 4: Sixteen thousand milliliters is the correct amount of IV fluid for resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 2.2 = 100 kg) 4 mL 100 kg 40% = 16,000 mL.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-6: Explain priorities in the care of the patient with major burns during the resuscitation phase.

Question 15

Type: MCMA

The nurse plans care for a client with a major burn injury keeping in mind that the goals for initial burn wound management would include:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Decrease the risk of developing compartment syndrome.

2. Promote physical/psychological comfort.

3. Prevent infection.

4. Reduce the degree of scarring.

5. Decrease fluid and electrolyte loss.

Correct Answer: 1,3,5

Rationale 1: The goals of wound management at this stage include decreasing the risk of developing compartment syndrome.

Rationale 2: Comfort is an important issue for treatment, however it is a secondary measure.

Rationale 3: The goals of wound management at this stage include preventing infection.

Rationale 4: Reduction of scarring is an issue that can be addressed at a later time.

Rationale 5: The goals of wound management at this stage are to decrease fluid and electrolyte losses.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-7: Discuss wound management during the acute phase following burn injury.

Question 16

Type: MCSA

A patient is complaining of increased pain to the area of a third-degree burn covering the entire arm. The nurse suspects compartment syndrome. For which intervention would the nurse prepare the patient?

1. Transportation to the whirlpool

2. Application of multiple ace wraps over the current gauze dressing

3. An escharotomy performed by the physician

4. Skin grafting performed by the physician

Correct Answer: 3

Rationale 1: The whirlpool would provide no remedy for the impaired circulation.

Rationale 2: Ace wraps would provide no remedy for the impaired circulation.

Rationale 3: Circumferential burn wounds to the neck, chest, abdomen, and extremities are at risk for developing compartment syndrome. The burn eschar constricts the burned area at the same time that edema is causing subcutaneous fluid expansion. The net result is impaired circulation to the involved area. Compartment syndrome is prevented by performing an escharotomy whereby the physician uses a scalpel or electrocautery to cut through the eschar, which releases tension and permits blood flow to the area. Escharotomies are usually performed at the bedside. The nurse should be prepared to assist in draping and monitoring the patient during the procedure.

Rationale 4: Skin grafting would provide no remedy for the impaired circulation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-7: Discuss wound management during the acute phase following burn injury.

Question 17

Type: MCSA

Which statement would the nurse use to explain skin covering procedures to a burn patient?

1. Autografts are permanent skin replacement for burns.

2. Meshed autografts are used for the face and hands.

3. Tissue typing is necessary for use of an allograft.

4. Cultured autologous epithelial cells provide a temporary wound covering.

Correct Answer: 1

Rationale 1: Autografting is a procedure that involves removing thin slices of unburned skin from an unburned donor site and placing it on top of the excised burn wound as a permanent means of coverage.

Rationale 2: Meshed autografts result in more scarring and are placed, when possible, on the back, buttocks, and thighs.

Rationale 3: Cadaver skin (allograft) is often used to temporarily cover excised skin, and tissue typing is not performed. Therefore, allograft results in a temporary coverage until it sloughs from the wound bed.

Rationale 4: Cultured autologous epithelial cells manufactured by Genzyme are the only commercially available permanent skin covering available in the United States. The cost of autologous epithelial autograft is considerable and use is reserved for patients with very large burns and few donor sites.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 17-7: Discuss wound management during the acute phase following burn injury.

Question 18

Type: MCSA

In preparing a patient for the rehabilitation phase of burn management, which statement reflects understanding of discharge teaching following a 6-month hospitalization?

1. I need to begin cutting back on calories to avoid weight gain.

2. I should have regular osteoporosis screening.

3. I will likely not tolerate cold weather anymore.

4. I must avoid getting a flu shot this year.

Correct Answer: 2

Rationale 1: Hypermetabolism is sustained for 9 to 12 months following burn injury. The patients weight should be monitored closely throughout the rehabilitation phase. The patient may still require supplemental enteral nutrition or high- caloric nutritional supplements to maintain a positive energy balance.

Rationale 2: I should have regular osteoporosis screening is correct and reflects understanding of discharge teaching. Large burn injuries have been associated with bone density losses and may be at increased risk for osteoporosis and pathologic fractures.

Rationale 3: Thermoregulation disturbances continue throughout the rehabilitation phase and the patient may experience heat intolerance.

Rationale 4: Following burn injury, there is an increased susceptibility to infection and appropriate precautions should be taken. This includes avoiding unnecessary exposure to people with colds or infections and maintaining up-to-date immunizations.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 17-8: Develop a plan to meet the needs of the burn injury patient during the rehabilitation phase.

Question 19

Type: MCMA

The nurse has reviewed plans for wound and scar management for the rehabilitation phase following an extensive burn with a patient and explains about complications that can occur including:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Neuropathies

2. Wound breakdown

3. Contractures

4. Hypertrophic scarring

5. Osteomyelitis

Correct Answer: 1,2,3,4

Rationale 1: Neuropathies can develop as a result of scar formation, edema, or improper positioning of splints or dressings.

Rationale 2: The maturing burn scar is fragile and susceptible to wound breakdown from shearing and pressure.

Rationale 3: Wound contractures occur as a result of scar formation over joints, which limit joint movement.

Rationale 4: In areas of the wound with granulation tissue, collagen deposition can be disorganized, resulting in the development of a hypertrophic scar, which is erythematous and raised.

Rationale 5: Osteomyelitis (bone infection) is not considered a typical wound or scar complication during the rehab phase.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-8: Develop a plan to meet the needs of the burn injury patient during the rehabilitation phase.

Question 20

Type: MCMA

An 80-year-old patient is admitted for 39% TBSA burns. The nurse would assess for which risk factors that apply to this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Higher sensitivity to pain

2. Delay seeking treatment

3. Thinner skin

4. Impaired vision

5. Concurrent respiratory problems

Correct Answer: 2,3,5

Rationale 1: Older patients have a decreased sense of pain.

Rationale 2: The older patient may delay seeking treatment for the burn due to a diminished sense of pain.

Rationale 3: Older patient have thinner skin, so when they experience burn injuries they often get more severe burns at lower temperatures and in less time than younger patients.

Rationale 4: Older adults with impaired hearing and not vision often do not have fire alarms that compensate for their impairment, they may not hear an alarm, and they may not be able to evacuate a burning building promptly.

Rationale 5: Older adults are more likely to have concurrent respiratory problems (COPD, asthma, or lung cancer).

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-9: Analyze the specific needs of older adult patients with a burn injury.

Question 21

Type: MCSA

The nurse is caring for an older patient with a burn injury. Because preexisting health conditions influence how the older patient responds to the resuscitative treatment, the priority when caring for this patient would be:

1. Calculating nutritional needs

2. Coordinating physical therapy

3. Managing pain

4. Fluid resuscitation

Correct Answer: 4

Rationale 1: This is not the immediate priority.

Rationale 2: This is not the immediate priority.

Rationale 3: This is not the immediate priority.

Rationale 4: Based on the strategy of ABCs (airway, breathing, and circulation), fluid resuscitation is the greatest priority. The patient with heart problems must be closely monitored during fluid resuscitation and a balance must be maintained between providing adequate resuscitation to the tissues and further stressing the heart.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-9: Analyze the specific needs of older adult patients with a burn injury.

Question 22

Type: MCMA

The intensive care nurse is assessing a patient for cardiovascular system changes related to a burn injury. Which findings are associated with a burn injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hypertension

2. Altered capillary refill

3. Hypovolemic burn shock

4. Peripheral extremity vascular compromise

5. Cardiac dysrhythmias

Correct Answer: 2,3,4,5

Rationale 1: With any type of shock, the patient would experience hypotension.

Rationale 2: One cardiovascular change after a burn injury is peripheral extremity vascular compromise.

Rationale 3: The most common cardiovascular change is hypovolemic burn shock.

Rationale 4: One cardiovascular change after a burn injury is peripheral extremity vascular compromise.

Rationale 5: One cardiovascular change after a burn injury is alterations in cardiac rhythm.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-4: Explain the changes within body system that occur following a burn injury.

Question 23

Type: MCSA

A patient is experiencing high levels of anxiety following a house fire. The nurse would administer which medication to help reduce the anxiety?

1. Fentanyl

2. Lorazepam

3. Hydromorphone

4. Sertraline

Correct Answer: 2

Rationale 1: Fentanyl would be used for pain management.

Rationale 2: Anxiolytics such as lorazepam may be used if the patient is experiencing high anxiety.

Rationale 3: Hydromorphone would be used for pain management.

Rationale 4: Sertraline is an antidepressant, which can lower anxiety; however, it may take 4 weeks or more to be effective.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5: Describe initial assessment and management of a patient with a burn injury.

Question 24

Type: MCSA

The nurse plans a burn prevention program for older persons at a neighborhood association meeting. The visual aid developed by the nurse to emphasize the most common cause of burn injuries in an older adult would be:

1. A lit cigarette

2. A bathtub of hot water

3. Pots and pans on a stove

4. Frayed electrical wires

Correct Answer: 3

Rationale 1: Fires caused by smoking are the leading cause of death in the older adult.

Rationale 2: Scalds are not the leading cause of burn injuries in the older adult.

Rationale 3: The picture of the pots and pans would be the best visual aid because approximately 3,000 older adults are injured in residential fires each year, with cooking fires being the leading cause of injuries.

Rationale 4: Electrical fires are not the leading cause of burn injuries in the older adult.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-9: Analyze the specific needs of older adult patients with a burn injury.

Question 25

Type: MCSA

During the acute phase of burn injury, the patient has the risk of developing complications. The nurse would assess for the presence of:

1. Hypovolemic shock

2. Septic shock

3. Wound scarring

4. Urinary tract infection

Correct Answer: 2

Rationale 1: This would occur during the resuscitative phase due to large amount of fluid loss.

Rationale 2: During the acute phase, fluid resuscitation is complete and the patient is at risk for sepsis and septic shock.

Rationale 3: This would occur during the rehabilitative phase as healing is occurring.

Rationale 4: Even though the presence of an indwelling urinary catheter can contribute to a urinary tract infection, it is not unique to the burn patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-7: Discuss wound management during the acute phase following burn injury.

Question 26

Type: MCMA

The nurse is caring for a patient who was brought into the emergency department after being struck by lightning. This patients injuries will most likely be to which body areas?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Heart

2. Soft tissue

3. Bones

4. Kidneys

5. Lungs

Correct Answer: 1,2,3

Rationale 1: Electrical injury may result in cardiac dysrhythmias that can lead to cardiopulmonary arrest.

Rationale 2: Electrical injuries may result in tissue destruction, which is not easily assessed.

Rationale 3: Electrical injuries may result in bone destruction, which is not easily assessed.

Rationale 4: Electrical injuries do not target the kidneys.

Rationale 5: Electrical injuries do not target the lungs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-1: Explain the common etiologies of burn injuries.

Question 27

Type: FIB

A patient sustained burns to the following body areas: both upper anterior arms, both lower anterior legs, and the anterior face and neck. The nurse uses the rule of nines to calculate this patients total body surface area that is burned as being:

Standard Text: Record your answer rounding to one decimal place.

Correct Answer: 31.5

Rationale : The upper anterior arm surface is a total of 9%. The lower anterior leg surface is 18%. The anterior face and neck is 4.5%. This patients total body surface area burned is 31.5%

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-2: Evaluate the severity of a burn injury.

Question 28

Type: MCMA

The nurse is caring for a patient who was in a house fire. The patient currently has a hoarse voice and has soot in the sputum. Over the next 24 hours, what will the patient experience as manifestations of a lower airway injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increased mucous production

2. Bronchospasm

3. Alteration in breath sounds

4. Chest pain

5. Peripheral neuropathy

Correct Answer: 1,2,3

Rationale 1: Chemical irritation of the alveolar tissue causes increased mucous production.

Rationale 2: Chemical irritation of the alveolar tissue causes bronchospasm.

Rationale 3: After 24 hours the patients chest x-ray may show the development of patchy atelectasis.

Rationale 4: Chest pain is not a manifestation of a lower airway injury.

Rationale 5: Peripheral neuropathy is not a manifestation of a lower airway injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-3: Describe the manifestations of an inhalation injury.

Question 29

Type: MCMA

The critical care nurse is concerned that a patient in the acute phase of a burn injury is experiencing metabolic changes because of which assessment findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Drop in body weight

2. Elevated creatinine levels

3. Urine output of 20 mL/hr

4. Abdominal pain

5. Stridor

Correct Answer: 1,2

Rationale 1: Hypermetabolism causes a drop in body weight during the acute phase of a burn injury.

Rationale 2: Hypermetabolism causes creatinine levels to increase during the acute phase of a burn injury.

Rationale 3: Urine output is an indication of fluid and renal status effects and not a result of metabolic changes.

Rationale 4: Abdominal pain is an indication of gastrointestinal status effects and not a result of metabolic changes.

Rationale 5: Stridor is an indication of respiratory effects and not a result of metabolic changes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-4: Explain the changes within body systems that occur following a burn injury.

Question 30

Type: MCMA

After the initial assessment of burn injuries it is determined that the patient will be transferred to a burn center for care. What assessment findings contributed to this decision?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Burns on the face

2. Burns on the hands

3. Burns to both hips

4. Burn to the perineum

5. Burns to the upper left arm and lower right leg

Correct Answer: 1,2,3,4

Rationale 1: Burn injuries that should be referred to a burn center include burns to the face.

Rationale 2: Burn injuries that should be referred to a burn center include burns to the hands.

Rationale 3: Burn injuries that should be referred to a burn center include burns to major joints.

Rationale 4: Burn injuries that should be referred to a burn center include burns to the perineum.

Rationale 5: These burn injuries would not necessitate the patient to be transferred to a burn center.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-5: Describe initial assessment and management of a patient with a burn injury.

Question 31

Type: MCMA

A patient weighing 80 kg is receiving resuscitative care for a burn to 46% of total body surface area. What findings indicate that resuscitation is being effective?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Urine output 50 mL/hour

2. Heart rate 96 beats per minute

3. Blood pressure 138/88 mm Hg

4. Clear lung sounds

5. Bladder pressure 15 mm Hg

Correct Answer: 1,2,3,4

Rationale 1: Burn resuscitation is considered successful when the patient has adequate urine output after 2 hours of fluids administered at maintenance rate. The urine output should be 0.5 to 1.0 mL/kg/hr.

Rationale 2: Acceptable parameters include a heart rate less than 120 beats per minute.

Rationale 3: A blood pressure that is normal to slightly hypertensive is evidence of successful resuscitation.

Rationale 4: Clear lung sounds is evidence of successful resuscitation.

Rationale 5: Bladder pressure is not used to assess effectiveness of resuscitative care.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 17-6: Explain priorities in the care of the patient with major burns during the resuscitation phase.

Question 32

Type: MCMA

The nurse is assisting with the initial debridement of a patients burn wounds. What will be done during this debridement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Cleaning the wounds with warm water and wound cleanser

2. Removing loose skin with gauze

3. Trimming skin tags with scissors

4. Shaving the hair around the wound

5. Washing the debrided wound with hot water and liquid soap

Correct Answer: 1,2,3,4

Rationale 1: Debridement of major burn wounds involves cleaning the burn wound with warm water or sterile saline and antimicrobial soaps or wound cleansers.

Rationale 2: Debridement of major burn wounds involves removing loose skin with gauze.

Rationale 3: Debridement of major burn wounds involves trimming skin tags with scissors.

Rationale 4: Debridement of major burn wounds involves shaving the hair around the wound.

Rationale 5: The debrided wound is washed with warm water or normal saline.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-7: Discuss wound management during the acute phase following burn injury.

Question 33

Type: MCMA

What interventions will the nurse plan to prevent the onset of contractures for a patient in the rehabilitation phase of burn care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Conduct exercises.

2. Splint joints.

3. Follow body positioning recommendations.

4. Perform range-of-motion exercises.

5. Schedule surgery to release the joints.

Correct Answer: 1,2,3

Rationale 1: Contractures are prevented by performing exercises as prescribed by physical therapy.

Rationale 2: Contractures are prevented by joint splinting.

Rationale 3: Contractures are prevented by appropriate body positioning.

Rationale 4: Range-of-motion exercises are used to treat contractures.

Rationale 5: Surgery to release the joints is used to treat contractures that are unresponsive to therapy and not to prevent contractures from developing.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-8: Develop a plan to meet the needs of the burn injury patient during the rehabilitation phase.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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