NUR 265 EXAM 3 - QUESTIONS AND ANSWERS

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NUR 265 Exam 3 Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action? Correct Answer: Document the findings ... Why? Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this Three days after a burn injury, the client develops a temperature of 100° F, white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which Correct Answer: Wound infection wound to the LPN. Which instruction is most important for the RN to provide the LPN? Correct Answer: Wash hands upon entering the clients room What intervention will the nurse implement to reduce a client's pain after a burn injury? Correct Answer: Administer 4mg Morphine IV What statement indicates the client needs further education regarding the skin grafting (allografting)? Correct Answer: "Because the graft is my own skin, there is no chance it won't 'take.' When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? Correct Answer: Changing gloves between wound care on different parts of the client's body Which assessment finding assists the nurse in confirming inhalation injury? Correct Answer: Brassy cough Which finding indicates that fluid resuscitation has been successful for a client with a burn injury? Correct Answer: Urine output = 50ml/HR Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance? Correct Answer: Performing his own morning care. Why? Indicators that the client with a burn injury has a positive perception of his appearance includes the willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the Which finding indicates to the nurse that the client understands the psychosocial impact of his severe burn injury? Correct Answer: It is normal to feel depressed. Which finding is characteristic during the emergent period after a deep full thickness burn injury? Correct Answer: Urine output of 10ml/hr Why? During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreaseD. Foul-smelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns. Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain? Correct Answer: Decreased tissue perfusion Why? During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury and a disrupted breathing pattern. Disturbed body image and disuse syndrome can develop. However, these are not priority diagnoses at this time. Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report to the physician immediately? Correct Answer: Serum potassium,7.5 mmol/L (mEq/L) Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury? Correct Answer: Allowing the client to eat whenever he or she wants Why? Clients should request food whenever they think that they can eat, not just according to the hospital's standard meal schedule. The nurse needs to work with a nutritionist to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications. hich statement best exemplifies the client's understanding of rehabilitation after a full-thickness burn injury? Correct Answer: "My goal is to achieve the highest level of functioning that I can" Which statement indicates that a client with facial burns understands the need to wear a facial pressure garment? Correct Answer: "My facial scars will be less with the use of this facial mask" he client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action Correct Answer: Loosen the dressing During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? Correct Answer: Increased serum creatinine levels. The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? Correct Answer: MI 1 year ago A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? Correct Answer: Learning to perform dressing changes A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? Correct Answer: Begin IV fluids A client who was burned has crackles and a respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first? Correct Answer: Place the client in an upright position. Why? Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in the upright position can relieve t [Show More]

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