NUR 410 Med-Surg Final Exam Questions & Answers-Which IV solution should the nurse anticipate administering to a client who sustained severe
... [Show More] burns?
A.
D5W (5% dextrose in water)
B.
Lactated Ringers solution
C.
D5 1/2 normal saline with 20 mEq of potassium chloride.
D.
Hespan - B.
Lactated Ringers solution
The nurse on the burn unit provides care for a client with a new autograft on the left elbow. Which actions does the nurse take to improve skin graft outcomes? (select all that apply)
A.
Conduct range of motion exercises daily.
B.
Maintain gauze dressing over autograft for 3-5 days.
C.
Assist with incentive spirometry hourly while awake.
D.
Increase ambulation to tolerance.
E.
Immobilize the left arm. - B & E
The nurse assesses a newly admitted client following a burn injury. Which assessment findings cause the nurse to suspect inhalation injury? (Select all that apply)
Facial burns
Singed nasal hair
Hemoptysis
Heart rate 112 beats/min
Audible Stridor - Audible stridor
Facial burns
Singed nasal hair
A client admitted to the emergency room with burns covering 45% of the total body surface area (TBSA) requires aggressive fluid resuscitation. What is the anticipated duration for fluid resuscitation intervention?
.
12 hours
B.
24 hours
C.
48 hours
D.
72 hours - B.
24 hours
The clinic nurse instructs a client with partial-thickness burns of the thighs on how to clean and dress the wounds. At the next visit, the nurse notes the wounds are dirty and not covered by dressings. What actions does the nurse take?
A.
Inform the client the health care provider will not treat someone who is noncompliant.
B.
Review the dressing change, using the teach-back method.
C.
Ask the client why she is not following the instructions.
D.
Describe the physiology of burn healing and infection processes. - B.
Review the dressing change, using the teach-back method.
The triage nurse assesses a client with burns on the right arm and leg. The client is crying with pain, the burnt skin is red, and large wet blisters are present. Which depth of injury does the nurse suspect?
A.
Full thickness burn
B.
Superficial partial thickness burn
C.
Superficial burn
D.
Deep partial thickness burn - B.
Superficial partial thickness burn
What pain medication should the nurse administer to a client with a 35% TBSA burn?
A.
Morphine IVP
B.
Fentanyl patch
C.
Ketorolac IVP
D.
Morphine IM - A. Morphine IVP
While collecting a medical history on a client who experienced a severe burn, which statement by the client's husband requires intervention?
A.
"She takes medication for menopause."
B.
"I think it has been at least 15 years since her last tetanus shot".
C.
"She smokes 1.5 packs of cigarettes a day."
D.
"She found out she has COPD about 2 years ago." - B. "I think it has been at least 15 years since her last tetanus shot".
A client has burns covering the anterior torso, anterior arms (bilateral), and anterior legs (bilateral). What percentage of the total body surface area (BSA) does the nurse estimate is affected? (Record your answer rounding to the nearest whole number.)
27 %
45 %
54 %
72 % - 45 %
A client sustains major burns on the anterior thorax, head, and bilateral upper extremities following a house fire. What is the initial
A.
Restore hemodynamic stability.
B.
Maintain patent airway.
C.
Prevent infection.
D.
Initiate intravascular resuscitation. - B.
Maintain patent airway.
During Fluid Resuscitation, how much fluid should be administered in the first 8 hrs? And then the next 16 hrs? - Half of the fluid is given in the first 8hrs. The remaining is given in the next 16 hrs.
Care for graft site - elevate and immobilize the graft site
keep free from pressure
avoid weight bearing activities
use cotton tip to removed exudate
monitor for signs of infection
avoid softeners/hard detergents
protect from sun light
use splints as prescribed
How long must compression dressing be worn each day? and for what purpose? - 23 out of 24 hours. Saves mobility and prevents scarring
Important concepts for burns - -Cardiac monitoring
-Infection Control
-Shock (sepsis)
A client is brought to the emergency department with 35% TBSA burns. Which actions should the nurse implement for this client?
A.
Administer oxygen as required.
B.
Apply a cooling blanket on the client.
C.
Assess airway for patency.
D.
Elevate extremities if no fractures are present.
E.
Administer IVF resuscitation.
F.
Administer IM pain medication as needed - A, C, D, E
Which client should the nurse see first?
A.
The client with burns to the chest and neck while grilling.
B.
The client with a burn to her left hand and arm from spilling boiling water.
C.
The client with a full-thickness burn to the leg from riding his motorcycle.
D.
The client with a chemical burn to his left leg. - A.
The client with burns to the chest and neck while grilling.
Review the client's information below and identify the intervention to implement first.
Vital Signs
Temperature 97.6 orally
Heart Rate: 114
Respiratory Rate: 24
Blood Pressure 98/54
Oxygen Saturation 94 on venturi mask
Assessment
Serous exudate from the wound
Lungs clear to auscultation but diminished
Urine output 20 ml for the past hours
Pain rating a 5 out of 10
A.
Administer prescribed antibiotics.
B.
Increase the IVF per order.
C.
Encourage the use of the incentive spirometer.
D.
Administer the PRN pain medication. - B.
Increase the IVF per oder.
An adult client was burned in a car fire. The client sustained a circumferential burn to the right arm, the anterior torso, and half of the anterior face. What percent of the body was burned using the rule of nines?
A.
15.75%
B.
27%
C.
29.25%
D.
31.5% - C.
29.25%
Which is the most serious complication for which the nurse must monitor a client with kidney failure?
A.
Platelet dysfunction
B.
Hyperkalemia
C.
Weight loss
D.
Anemia - B.
Hyperkalemia
A client who has been receiving hemodialysis for several years is to receive a kidney transplant. What should the nurse say in the client's preoperative teaching plan? Select all that apply.
A.
The kidney may not function immediately
B.
Precautions are needed to prevent infection
C.
A urinary catheter will be in place postoperatively
D.
The atrioventricular fistula will be used for drawing blood specimens preoperatively
E.
Immunosuppressive medications will be given a week before surgery - A.
The kidney may not function immediately
B.
Precautions are needed to prevent infection
C.
A urinary catheter will be in place postoperatively
A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end stage renal disease (ESRD)?
A.
Sodium
B.
Fluid
C.
Protein
D.
Potassium - C.
Protein
A nurse is caring for a client who had a kidney transplant. Which test is most important for determining whether a client's newly transplanted kidney is working effectively?
A.
Renal scan
B.
White blood cell (WBC) count
C.
24-hour urine output
D.
Serum creatinine - D.
Serum creatinine
A client who is to begin continuous ambulatory peritoneal dialysis asks the nurse what this entails. What information should the nurse include when answering the client's question?
A.
Constant contact is maintained between the dialysate and the peritoneal membrane
B.
Peritoneal dialysis is performed in an ambulatory clinic
C.
About a quarter of a liter of dialysate is maintained in the peritoneal cavity
D.
Hemodialysis and peritoneal dialysis will be done together. - A.
Constant contact is maintained between the dialysate and the peritoneal membrane
A client develops kidney damage as a result of a transfusion reaction. What is the most significant clinical response that the nurse should assess when determining kidney damage?
A.
Glycosuria
B.
Acute flank pain
C.
Hematuria
D.
Decreased urinary output - D.
Decreased urinary output
The nurse would clarify which provider prescription for the client with acute kidney injury in the oliguric phase?
A.
Normal saline 125 ml/hr continuous intravenous infusion
B.
Furosemide 40 mg by mouth daily
C.
Place on a 1500 mg per day sodium restriction
D.
Decrease protein dietary intake - A.
Normal saline 125 ml/hr continuous intravenous infusion [Show Less]