Chapter 61 My Nursing Test Banks

Osborn,_2e
Chapter 61

Question 1

Type: MCMA

Which information will the nurse collect to assist in the classification of a burn injury as minor, moderate, or major?

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

Standard Text: Select all that apply.

1. Location of the burns on the body

2. The history of the event and location where the injury occurred

3. Any concurrent injuries

4. The time the injury occurred

5. The causative agent

Correct Answer: 1,2,3,5

Rationale 1: The location of the burns on the body is one of the important determinates of classification. For example, burns of the face and hands are always considered major burns.

Rationale 2: If the injury occurred in an enclosed area, such as a house, there also may be inhalation injuries that require special consideration and treatment. Inhalation injuries are considered major burns.

Rationale 3: If complicated injuries such as those from multiple traumas are present, the burn is considered a major burn.

Rationale 4: The time of the burn is not a burn classification criterion.

Rationale 5: The cause or manner of the burn is included in classification. For example, electrical burns are major burns.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-1

Question 2

Type: MCSA

The nurse is admitting a 25-year-old patient to the emergency department with partial-thickness injuries over 20% of the total body surface area, involving both lower legs. According to American Burn Association (ABA) guidelines, the nurse would classify this as which level of burn?

1. Minor

2. Major

3. Moderate

4. Severe

Correct Answer: 3

Rationale 1: A minor burn is a partial-thickness injury that involves less than 15% of total body surface area (TBSA) in adults.

Rationale 2: A major burn is a partial-thickness injury that involves more than 25% of total body surface area in adults (TBSA) or a full-thickness injury over 10% or more of TBSA.

Rationale 3: A moderate injury is a partial-thickness injury that involves between 15% and 25% of total body surface area in adults.

Rationale 4: Severe is not a classification used by the ABA.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-1

Question 3

Type: MCSA

The nurse has admitted a patient who sustained a partial-thickness burn injury of 28% of total body surface area (TBSA) and a full-thickness injury of 30% of TBSA. Which American Burn Association (ABA) classification would the nurse assign to this injury?

1. Moderate

2. Major

3. Superficial

4. Minor

Correct Answer: 2

Rationale 1: Partial-thickness injuries between 15% and 25% of total body surface area in adults and full-thickness injuries greater than 10% of TBSA not involving the ears, eyes, face, hands, feet, and perineum are moderate injuries.

Rationale 2: Partial-thickness injuries involving greater than 25% of total body surface area in adults and full-thickness injuries involving 10% or greater of TBSA are considered major burns.

Rationale 3: Superficial is not an ABA burn injury classification.

Rationale 4: Partial-thickness injuries of less than 15% of total body surface area (TBSA) in adults and full-thickness injuries less than 2% of TBSA not involving the ears, eyes, face, hands, feet, and perineum are considered minor injuries.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-1

Question 4

Type: MCMA

A patient sustained a radiation injury in an accident at a nuclear power plant. Which assessment questions would the nurse ask to determine the depth of this injury?

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

Standard Text: Select all that apply.

1. How close were you to the source?

2. How long were you exposed to the source?

3. How hot did the source get?

4. Was steam produced during the accident?

5. Where did the radiation enter and exit your body?

Correct Answer: 1,2

Rationale 1: The depth of a radiation injury depends in part on how close the individual was to the source.

Rationale 2: The depth of a radiation injury depends in part on the length of time of exposure.

Rationale 3: The temperature of the source is relevant to the depth and severity of thermal and scald injuries.

Rationale 4: Steam is relevant to the severity of scald injuries.

Rationale 5: Entry and exit wounds occur with electrical injuries.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-3

Question 5

Type: MCMA

The nurse is caring for a patient who was overexposed to radiation during cancer treatment. The nurse plans care with the knowledge that which cells are most susceptible to this type of radiation injury?

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

Standard Text: Select all that apply.

1. Skin cells

2. Gastrointestinal tract cells

3. Bone marrow cells

4. Kidney cells

5. Muscle cells

Correct Answer: 1,2,3

Rationale 1: The cells most susceptible to injury are those that divide rapidly, such as skin cells.

Rationale 2: The cells most susceptible to injury are those that divide rapidly, such as cells of the gastrointestinal tract.

Rationale 3: The cells most susceptible to injury are those that divide rapidly, such as bone marrow cells.

Rationale 4: Cells of the kidney are not as susceptible because they do not divide as rapidly as cells of other tissues.

Rationale 5: Muscle cells are not as susceptible because they do not divide as rapidly as cells of other tissues.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-3

Question 6

Type: MCMA

Surrounding tissue destroyed by burn is an area identified as the zone of stasis. Which nursing interventions are designed to protect this zone from further damage?

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

Standard Text: Select all that apply.

1. Strict adherence to infection control measures

2. Elevation of the burned area

3. Early focus on feeding the patient

4. Managing fluid resuscitation

5. Administration of medications to prevent myoglobin release from cells

Correct Answer: 1,2,4

Rationale 1: Infection control measures are part of the prompt and appropriate wound care necessary to protect this area.

Rationale 2: Elevation of the burned area helps to control edema.

Rationale 3: Nutrition is important in wound healing, but early feeding is not critical to the survival of these tissues.

Rationale 4: Systemic fluid resuscitation helps to support this tissue.

Rationale 5: Myoglobin release is not an immediate problem to these cells.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-3

Question 7

Type: MCSA

The nurse would anticipate which laboratory result drawn 10 hours after a patient experienced a major burn injury?

1. Potassium level of 3.0 mEq/L

2. Platelets 450,000 uL

3. Hematocrit of 48%

4. Sodium 138 mEq/L

Correct Answer: 3

Rationale 1: Cell damage resulting from the burn injury causes the release of intracellular potassium, which causes hyperkalemia. Therefore, the potassium level is increased, not decreased, in the first 24 hours.

Rationale 2: Large numbers of platelets are used to stabilize the vasculature in and around the burned area. Platelet counts typically drop.

Rationale 3: Hematocrit increases in the first 12 to 48 hours after a burn injury due to hemoconcentration from intravascular fluid volume loss.

Rationale 4: An increased serum sodium level is expected due to dehydration and fluid shifts.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-3

Question 8

Type: MCSA

The nurse is admitting a 50-year-old female who was involved in a car accident and whose only injuries were burns over 50% of her body. Identify the highest-priority nursing diagnosis for this patient.

1. Acute Pain

2. Coping: Family, Compromised

3. Disturbed Body Image

4. Deficient Fluid Volume

Correct Answer: 4

Rationale 1: Acute Pain is an important nursing diagnosis but does not have the highest priority.

Rationale 2: Family coping will probably be compromised and the nurse should address this issue. However, this is not the priority diagnosis.

Rationale 3: Disturbed Body Image is an important nursing diagnosis but is not the highest priority.

Rationale 4: Immediately after a burn injury, fluid begins to shift from the intracellular and intravascular compartment into the interstitial space. This third-spacing of fluid, if left untreated, will lead to hypovolemia and burn shock, which is life threatening. Also, edema develops in unburned tissues and organs distant from the site of injury when the burn size exceeds 20% of total body surface area.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 61-6

Question 9

Type: MCSA

During the immediate postburn period, the nurse conducts a rapid but thorough assessment. Which finding indicates a potential complication?

1. Coughing

2. Presence of eschar

3. Urine output of 30 mL in the hour since the burn occurred

4. Edema in the burned area

Correct Answer: 1

Rationale 1: Coughing could indicate either an inhalation injury or a cold. Any evidence of inhalation injury should be managed aggressively.

Rationale 2: Eschar may be present in severe burns.

Rationale 3: Urine output of 30 mL in the last hour is normal.

Rationale 4: Edema will likely be present at the site of the burn.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-4

Question 10

Type: MCMA

Which patient care goals does the nurse prioritize during the acute phase of burn treatment?

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

Standard Text: Select all that apply.

1. Preventing infection

2. Preventing loss of body heat through the wounds

3. Securing and maintaining the airway

4. Splinting, positioning, and exercising affected joints

5. Providing for patient comfort

Correct Answer: 1,2,4,5

Rationale 1: The prevention of infection continues to be a goal as the patient moves into the acute phase of burn care.

Rationale 2: The interruption of skin integrity results in loss of body heat. The health care team works to prevent this loss during the acute phase of burn treatment.

Rationale 3: Airway is always important, but the ABCs should have been addressed in the emergent phase of burn care.

Rationale 4: Return of function is supported by splinting, positioning, and exercising affected joints. This focus continues through the acute care period.

Rationale 5: Pain relief continues to be a focus of care in the acute phase of burn care.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 61-4

Question 11

Type: MCSA

During the acute period of burn care, a focus of care is to promote healing of full-thickness burn wounds. Which nursing interventions are necessary before this healing can begin?

1. Administration of diuretics to reduce edema in the wound bed

2. Pharmacologic and nonpharmacologic methods to achieve pain-free status

3. Debridement and cleansing to rid the wound bed of eschar

4. Nutritional support to return the patient to preburn weight

Correct Answer: 3

Rationale 1: Diuretics are not used to reduce this type of edema.

Rationale 2: The patient will not be pain free as long as the wound is open. Pain will decrease with wound closure but may continue into the rehabilitative phase.

Rationale 3: For the wound to heal, it must be free of the dead tissue resulting from burn injury.

Rationale 4: Efforts to return the patient to preburn weight continue throughout the acute phase as wound closure begins. It may be several months or years before preburn weight is achieved.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-4

Question 12

Type: MCMA

The mortality rate for burns is highest in the very young and in the elderly population. What factors put the very young at a higher risk?

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

Standard Text: Select all that apply.

1. The very young have a greater proportion of body surface area per amount of body mass, resulting in a higher risk for fluid-volume loss.

2. The very young tend to heal more slowly.

3. Infants and young children have an immature immune system with a weak antibody response.

4. The very young have a higher risk for the development of hypovolemic shock.

5. In the very young, burns tend to exacerbate previous medical problems.

Correct Answer: 1,3,4

Rationale 1: The very young have greater proportion of BSA relative to body mass, and as a result are at higher risk than adults for fluid-volume loss.

Rationale 2: This is true of the elderly, not the very young.

Rationale 3: Infants and young children have an immature immune system and tend to die of septicemia.

Rationale 4: As a result of a higher risk for fluid-volume loss, very young children have a higher risk for the development of hypovolemic shock.

Rationale 5: This is true of the elderly, not the very young.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-5

Question 13

Type: MCMA

The nurse manager of a burn unit is conducting education for newly hired nurses. What factors would the manager point to as reducing the rate of survival among burn patients?

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

Standard Text: Select all that apply.

1. History of substance abuse

2. Endocrine diseases

3. Renal disease

4. Cardiac disease

5. Previous burn injury

Correct Answer: 1,2,3,4

Rationale 1: Preinjury status is a major factor in an individuals ability to survive a burn injury. Patients who abuse substances are at risk for compromised health status.

Rationale 2: In the presence of endocrine abnormalities such as diabetes, the added insult of a burn injury exacerbates the disease and impacts wound healing and the immune response.

Rationale 3: The hypovolemia that occurs as a result of fluid shifts causes a decrease in renal blood flow and filtration rates, which increases the risk for renal failure.

Rationale 4: Previous cardiac disease increases the mortality rate because the added insult of burn injury is overwhelming. Stimulation of the sympathetic nervous system causes the release of catecholamines (epinephrine and norepinephrine), increases systemic vascular resistance, and thus increases cardiac workload.

Rationale 5: There is no specific reason that a person with a previous burn injury would have a lower chance of surviving a second burn injury.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-5

Question 14

Type: MCSA

Escharotomies have been performed on a patients arms because of circumferential burn injuries. What is the nurses highest assessment priority?

1. Circulation in the extremity distal to the escharotomy

2. Formation of contractures

3. Wound infection in the escharotomy site

4. Ability to perform range-of-motion exercises

Correct Answer: 1

Rationale 1: Frequent monitoring of the circulation distal to the escharotomy site is part of ongoing nursing assessment and includes pulses, tissue color, sensation, increased pain, capillary refill, and decreased temperature. Often it is necessary to monitor circulation every 15 to 20 minutes.

Rationale 2: Contracture formation occurs later, as the wounds heal.

Rationale 3: Wound infection would not occur immediately; therefore, it is not the first priority.

Rationale 4: Range of motion decreases as the wounds heal, not immediately.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-6

Question 15

Type: MCSA

A patient is scheduled to receive a meshed skin graft to begin closing a major burn injury. How would the nurse explain the rationale for using a meshed graft?

1. Meshing allows the graft to cover a larger area.

2. Meshing improves the look of the healed wound.

3. Meshing increases the thickness of the graft.

4. Meshing holds the serous fluid next to the wound.

Correct Answer: 1

Rationale 1: Meshing a graft means cutting holes in the harvested skin, which allows it to be stretched over a greater surface area. The meshed skin graft can be enlarged two to nine times its original size, depending on the size of the holes.

Rationale 2: Meshed skin grafts heal with the diamond pattern remaining for the rest of the patients life; they are not as cosmetically pleasing as sheet grafts.

Rationale 3: Meshing does not increase the thickness of the graft.

Rationale 4: Meshing allows for drainage of this fluid, which is an advantage of using meshed grafts.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-6

Question 16

Type: MCMA

A patient has sustained a burn injury to the anterior chest and neck and the right shoulder, arm, and hand. How should the nurse position 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. Extend the arm 90 degrees from the body.

2. Position the arm slightly in front of the midaxillary line.

3. Extend the elbow with the palm of the hand downward.

4. Extend the wrist.

5. Use a pillow to flex the neck.

Correct Answer: 1,4

Rationale 1: The arm should be extended 90 degrees from the side of the trunk.

Rationale 2: The arm should be positioned slightly behind the midaxillary line.

Rationale 3: The arm should be supinated with the palm of the hand upward.

Rationale 4: The wrist should be splinted to maintain 35 to 45 degrees of extension.

Rationale 5: No pillow should be used under the head. The neck should be in extension.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-6

Question 17

Type: FIB

A patient who sustained a burn injury over 65% of the body is in the acute phase of care. The patients preburn weight was 165 pounds. The nurse would work with the patient to achieve intake of ________ calories each day.

Standard Text:

Correct Answer: 4475

Rationale : (25 kilocalories x 75 kg) + (40 kilocalories x 65) = calories per day
1875 + 2600 = 4475 calories

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-6

Question 18

Type: MCSA

The nurse is preparing a patient for discharge from the hospital following a major burn injury. The nurse would consider which pathophysiology when developing a plan for the patients nutrition?

1. The hypermetabolic state is only present in the emergency and acute phases of burn care.

2. The hypermetabolic state continues until all the wounds are healed.

3. The major dietary need after discharge is additional oral fluids.

4. The calorie intake should be decreased so the patient does not stress new tissue with weight gain.

Correct Answer: 2

Rationale 1: The hypermetabolic state does not end with the acute phase of burn care.

Rationale 2: The hypermetabolic state continues until the burn wounds are completely healed, which can take up to 12 to 18 months after the injury. Therefore, it is essential that the patient continue with increased calorie and vitamin intake after discharge from the hospital.

Rationale 3: Oral fluids continue to be required, but other nutritional components are also essential.

Rationale 4: Reducing calorie intake is inappropriate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-7

Question 19

Type: MCMA

Which grief reactions would the nurse discuss with a patient who is being discharged from the hospital after treatment for major 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. Separation from home and family

2. Potential change in vocation

3. Change in family role patterns

4. Body image change

5. Loss of physical functioning

Correct Answer: 2,3,4,5

Rationale 1: The patient is now leaving the hospital so a major concern will be reintegration into the home and family routines.

Rationale 2: This is included in the grief response because it poses a threat to the patients financial independence.

Rationale 3: A shift in family role patterns, especially the breadwinner role, upsets the family structure and is a factor in the grief process.

Rationale 4: The change in body image is the primary reason for the grief response.

Rationale 5: Loss of physical functioning impacts many aspects of the grief reaction, such as change in vocation and change in family role patters.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-7

Question 20

Type: MCSA

The nurse is teaching a patient about the need for continued stretching exercises after discharge from burn treatment. The nurse evaluates that the patient understands what is necessary when the patient makes which statement?

1. If I stretch, I dont need to use my splints.

2. If the scar blanches, it means I have stretched too far.

3. A progressive exercise program will not increase my overall stamina.

4. Stretching exercises help increase the range of motion in my burned arm.

Correct Answer: 4

Rationale 1: Immediately after a stretching session, positioning and splinting are used to maintain the elongation of the tissue.

Rationale 2: Blanching of the scar represents appropriate stretching.

Rationale 3: Exercise not only improves joint flexibility but also improves overall stamina.

Rationale 4: Stretching exercises are used to elongate shortened soft tissue.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 61-7

Question 21

Type: MCSA

What factor would the nurse evaluate as putting the patient at increased risk for converting a partial-thickness burn injury to a full-thickness injury?

1. The patient develops a wound infection.

2. Assessment of the lungs indicates fluid overload.

3. The patient develops pneumonia.

4. The patients kidney function is compromised.

Correct Answer: 1

Rationale 1: Infection, trauma, and a decreased blood supply increase the risk of a partial-thickness injury converting to a full-thickness injury.

Rationale 2: Fluid overload would not affect the integrity of the burn wound. Hypovolemia could cause this conversion if it resulted in decreased blood supply to the wound.

Rationale 3: Pneumonia would not be a direct risk for conversion. If the patient became hypoxic, the wound would be affected.

Rationale 4: Compromise of kidney function is not directly related to this conversion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 61-3

Question 22

Type: MCSA

The nurse explains to a family that it is not possible to determine the extent of a patients burns after an accidental electrocution. What rationale does the nurse provide for this statement?

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

1. Much of the damage done by electrical burns is beneath the surface.

2. The temperature of electrical energy can exceed 180F.

3. The injury that is initiated by electrical energy does not stop when the current is interrupted.

4. The energy causing the burn affects rapidly dividing cells, which makes damage variable.

5. Electrical burns cause the same tissue response as alkali chemicals.

Correct Answer: 3

Rationale 1: Much of the damage done by electrical burns occurs internally because the electrical current travels along the tendons and vessels as it flows through the body.

Rationale 2: The temperature of electrical energy is not the reason it is difficult to assess the extent of electrical burns.

Rationale 3: The destructive process that is initiated at the time of injury continues for weeks.

Rationale 4: The energy from electrical burns does not affect rapidly dividing cells to a greater extent than cells that divide more slowly.

Rationale 5: Electrical burns do not have the same pathophysiological effect as alkali burns.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-2

Question 23

Type: MCMA

A patient sustained a serious electrical burn when he stepped on a downed power line. The nurse would assess for which injuries?

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

Standard Text: Select all that apply.

1. Fractures in the arms or legs

2. Cardiac dysrhythmia

3. Vision changes

4. Sooty sputum

5. Extensive partial-thickness burns

Correct Answer: 1,2,3

Rationale 1: The tetanic muscle contractions caused by electrical current can be strong enough to fracture long bones.

Rationale 2: Cardiac muscle contraction is controlled by electrical impulses. Strong electrical current across the heart can result in cardiac dysfunction.

Rationale 3: Electrical injury can cause cataract formation.

Rationale 4: Soot in the sputum is related to inhalation injury, not electrical injury.

Rationale 5: Extensive partial-thickness burns would be expected with thermal, chemical, or scald burns. The burns associated with electrical current are more likely to be internal.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-2

Question 24

Type: MCMA

A nurse is teaching mothers of preschoolers about how to prevent burn injuries. Which information should the nurse include in this teaching?

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

Standard Text: Select all that apply.

1. Set home hot water heaters at 130F.

2. Run cold water in the bathtub before adding hot water.

3. Check the temperature of childrens baths with the hand before putting the child in the bathtub.

4. Cook on front burners with the pot handle turned to the rear.

5. Place hot items in the middle of the table during meals.

Correct Answer: 2,5

Rationale 1: The maximum temperature of a home hot water heater should be 120F.

Rationale 2: Running cold water and adding hot water to modulate the temperature is safer than starting with hot water and adding cold water.

Rationale 3: The parent should check the temperature of the bathwater with the elbow because the hands are more resistant to high temperatures.

Rationale 4: It is safer to cook on back burners.

Rationale 5: If hot items are placed on the periphery of the table, a child may be burned by a spill.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-2

Question 25

Type: MCMA

Which interventions would the nurse perform to help prevent bacterial translocation in a patient who has suffered a severe 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. Administer glutamine as ordered.

2. Administer enteral feedings as ordered.

3. Administer potassium as ordered.

4. Monitor arterial blood gases.

5. Monitor creatinine.

Correct Answer: 1,2

Rationale 1: Glutamine is a dietary supplement that has been demonstrated to partially reverse the gut atrophy implicated in bacterial translocation.

Rationale 2: Early enteral feeding is thought to prevent or reduce bacterial translocation.

Rationale 3: Potassium imbalance is not implicated in bacterial translocation.

Rationale 4: The respiratory system is not involved in bacterial translocation.

Rationale 5: Kidney function is not involved in bacterial translocation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-3

Question 26

Type: MCMA

The nurse is monitoring for development of renal failure in a patient who sustained a moderate burn injury. Which laboratory results would be cause for concern?

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

Standard Text: Select all that apply.

1. BUN of 40 mg/dL

2. Creatinine of 1.9 mg/dL

3. Total protein of 5.8 g/dL

4. Creatine kinase of 350 U/L

5. Urine specific gravity of 1.020

Correct Answer: 1,2

Rationale 1: This BUN is high and may indicate renal disorder.

Rationale 2: The creatinine is high and indicates renal dysfunction.

Rationale 3: This total protein is low, but is likely due to fluid shifts or poor nutrition rather than renal dysfunction.

Rationale 4: CK is a muscle enzyme and would be increased due to muscle injury. It is not associated with renal dysfunction.

Rationale 5: This is a normal specific gravity, so it does not indicate dysfunction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-3

Question 27

Type: MCMA

A patient has been brought to the emergency department by ambulance after sustaining major burns in a house fire. The nurse would anticipate that which therapies have been initiated?

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

Standard Text: Select all that apply.

1. Jewelry has been removed.

2. Ice bags have been applied to burned areas.

3. The burn has been covered with a clean sheet.

4. Tetanus prophylaxis status has been determined.

5. Burn ointment has been applied to all partial-thickness burns.

Correct Answer: 1,3,4

Rationale 1: Jewelry that might add to the burn injury should be removed as part of prehospital care.

Rationale 2: Ice should not be applied due to the possibility of additional injury.

Rationale 3: Placement of a clean sheet over the burned area may reduce pain and protect the wound.

Rationale 4: The patient with burn injury is at risk for tetanus. Depending on the date of the last tetanus injection, a form of tetanus prophylaxis will likely be necessary.

Rationale 5: Ointment should not be applied to any burns.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-4

Question 28

Type: FIB

The nurse is estimating the extent of burns on an adult patient just admitted to the emergency department. The patient has burns on both arms, the anterior trunk, and the right leg. The nurse estimates that _______ % of total body surface area is involved.

Standard Text:

Correct Answer: 54

Rationale : The arms are 9% each, the anterior trunk is 18%, and the leg is 18%, for a total of 54% of total body surface area.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-5

Question 29

Type: FIB

An adult patient who weighs 220 pounds has been burned over 70% of the body. Using the Parkland/Baxter formula, the nurse would anticipate administering ______ mL of fluid in the second 8 hours after the patient was burned.

Standard Text:

Correct Answer: 7,000

Rationale : 220 pounds = 100 kg
100kg x 4 mL x 70 =28,000 mL in first 24 hours. Half (14,000mL) is given in the first 8 hours; 7,000 mL is given in the second 8 hours.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 61-6

Question 30

Type: FIB

A patient who weighs 132 pounds sustained a burn injury and is receiving fluid resuscitation. The nurse would evaluate adequate hydration if the patient is producing at least ________ mL of urine each hour.

Standard Text:

Correct Answer: 30

Rationale : This patient weighs 60 kg. Adequate urine output is 0.5 to 1 mL/kg/hr. 60 kg x 0.5 = 30 mL

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 61-6

Question 31

Type: MCSA

A patient has sustained a moderate burn injury and requires pain management. Which medication prescription should the emergency department nurse implement?

1. Morphine sulfate 4 mg IV every 2 hours

2. Fentanyl 50 mcg IM every 2 hours

3. Codeine 30 mg PO every 3 hours

4. Ibuprofen 800 mg PO every 6 hours

Correct Answer: 1

Rationale 1: Opioids are appropriate for pain control and should be given IV during the emergency phase of burn care.

Rationale 2: Pain medications are not administered IM during the emergency treatment of burns due to poor absorption.

Rationale 3: Pain medication should be administered via a different route.

Rationale 4: Initial pain control is achieved with opioids. NSAIDs are used as the burn injury heals.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-6

Question 32

Type: MCSA

A patient is severely burned over the neck, chest, both arms, and both legs. How should the nurse facilitate fluid resuscitation of this patient?

1. Defer placement of an IV line until the physician can place a central line.

2. Carefully assess the arms and legs for nonburned venous access.

3. Start a small-bore IV catheter in a nonburned area of the hand.

4. Start large-bore IV catheters through burned areas.

Correct Answer: 4

Rationale 1: The nurse should not defer IV line placement.

Rationale 2: The nurse should not take time for a careful assessment.

Rationale 3: A small-bore catheter is not sufficient for venous access.

Rationale 4: Though not optimal, the nurse should start large-bore IV catheters through burned flesh to begin fluid therapy as soon as possible.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-6

Question 33

Type: MCSA

The patient is scheduled for a heterograft to cover a burn wound. How would the nurse explain the source of this graft?

1. This graft is made from pigskin.

2. This graft is from a living donor.

3. This is a cadaver graft.

4. This graft will be taken from a nonburned area on your body.

Correct Answer: 1

Rationale 1: Heterografts are made with tissue from another species, such as pigskin.

Rationale 2: Living donor grafts are allografts.

Rationale 3: Cadaver grafts are allografts.

Rationale 4: Grafts taken from the patient are autografts.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 61-6

Question 34

Type: MCSA

Which intervention should the nurse plan for a patient who has a sheet skin graft covering a burn on the forearm?

1. Scrub the graft site with mild soap and water twice daily.

2. Perform range-of-motion exercises twice each shift.

3. Use aseptic technique for all contact with the graft.

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