Lippincott’s NCLEX RN Review for Med Surg test 1 Exam Solution 2023
1. There has been a fire in an apartment building.
All residents have been
... [Show More] evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply.
• 1. An 8-year-old with third-degree burns over 10% of his body surface area (BSA).
• 2. A 20-year-old who inhaled the smoke of the fire.
• 3. A 50-year-old diabetic with first- and second degree burns on his left forearm (about 5% of his BSA).
• 4. A 30-year-old with second-degree burns on the back of his left leg.
• 5. A 40-year-old with second-degree burns on his right arm (about 10% of his BSA). - 1 . 1, 2, 3. Clients who should be transferred to a burn center include children under age 10 or adults
over age 50 with second- and third-degree burns on 10% or greater of their body surface area (BSA), clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients on my age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.
2. The nurse in the immediate care clinic is assessing an 80-year-old client who lives with his son’s family and has scald burns on his hands and both forearms (first- and second-degree burns on10% of his body surface area). What should the nurse do first?
• 1. Clean the wounds with warm water.
• 2. Apply antibiotic cream.
• 3. Refer the client to a burn center.
4. Cover the burns with a sterile dressing. - 2. 3. The nurse should have the client transited to a burn center. The client's age and the extent of the burns require care by a burn teamed the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.
3. During the emergent (resuscitative) phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation?
• 1. Serum creatinine level of 2.5 mg/dL.
• 2. Little fluctuation in daily weight.
• 3. Hourly urine output of 60 mL.
• 4. Serum albumin level of 3.8. - 3. 1. Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/hour.
Fluid replacement is based on the Parkland or
Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 gm/dL.
4 . A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," the nurse would determine that about what percentage of the client's body surface has been burned?
• 1. 18%.
• 2. 27%.
• 3. 45%.
• 4. 64%. - 4. 3. According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%. [Show Less]