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WorksheetsExam 5- burns, old people, and ChRiStMaS
Total questions: 46
Worksheet time: 23mins
The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?
Superficial
Partial-thickness superficial
Full thickness
Partial-thickness deep
Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury?
Vitamin A
Vitamin D
Vitamin C
Vitamin B
Which client factors should alert the nurse to potential increased complications with a burn injury?
The client is a 26-year-old male.
The burn took place in an open field and ignited the client’s clothing.
The burned areas include the hands and perineum.
The client has had a burn injury in the past.
What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?
The burn is full thickness rather than partial thickness.
The client cannot distinguish the sensation of sharp versus dull in the extremity.
Capillary refill is slow in the digits and the distal pulse is absent.
The client is unable to fully pronate and supinate the extremity.
What additional laboratory test should be performed on any African American client who sustains a serious burn injury?
Total protein
Hemoglobin levels
Prostate-specific antigen
Tissue type antigens
The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action?
Raise the head of the bed.
Document the findings as the only action
Loosen the dressings on the chest.
Notify the emergency team.
Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action?
Notify the emergency team.
Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.
Ask the client if anyone in her family has diabetes mellitus.
Document the finding as the only action.
On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury–related response?
Fluid shift
Carbon monoxide poisoning
Hemorrhage
Intense pain
All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately?
Serum sodium elevated to 131 mmol/L (mEq/L)
Hematocrit is 52%
Arterial pH is 7.32
Serum potassium 7.5 mmol/L (mEq/L)
The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission?
Airway patency
Current range of motion in all extremities
Heart rate and rhythm
Orientation to time, place, and person
In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?
“Are you a smoker?”
“In what exact place or space were you when you were burned?”
Have you ever had asthma or any other lung problem?”
“When was your last chest x-ray?”“
Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?
The client is able to talk.
.The client’s chest movements are uninhibited
The client’s oxygen saturation is 97%
The client is alert and oriented.
The burned client’s family ask at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?
“When fluid remobilization has started.”“
“When body weight is normal.”
“When IV fluids are discontinued.”
When the burn wounds are closed.”
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?
seasonal asthma
hepatitis B 10 years ago
Myocardial Infarction 1 year ago
kidney stones within the last 6 months
The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?
Assess level of consciousness and pupillary reactions.
Measure abdominal girth and auscultate bowel sounds in all four quadrants.
.Auscultate breath sounds over the trachea and mainstem bronchi.
Ask the client at what time food or liquid was last consumed
Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?
Handwashing on entering the client’s room
Changing gloves between cleansing different burn areas
Administering the prescribed tetanus toxoid vaccine
Encouraging the client to cough and deep breathe
The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?
Place a towel roll under the client’s neck or shoulder.
Keep the client in a semi-Fowler’s position and actively raise the arms above the head every hour while awake.
Have the client turn the head from side to side 90 degrees every hour while awake.
Keep the client in a supine position without the use of pillows.
The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintains to retain maximum function of this joint?
Hip maintained in 30-degree flexion, no knee flexion
Hip at zero flexion with leg flat
Hip, knee, and ankle all at maximum flexion
Hip flexed 90 degrees and knee flexed 90 degrees
Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?
Changing gloves between wound care on different parts of the client’s body.
Using proper and consistent handwashing.
Using the closed method of burn wound management.
Avoiding sharing equipment such as blood pressure cuffs between clients.
When should ambulation be initiated in the client who has sustained a major burn?
When all full-thickness areas have been closed with skin grafts
As soon as possible after resolution of the fluid shift
As soon as possible after wound debridement is complete
When the client’s temperature has remained normal for 24 hours
What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?
“For the first few days after surgery, the donor sites will be painful.”
“Once all grafting is completed, my risk for infection is the same as it was before I was burned.”
“I will have some scarring in the area when the skin is removed for grafting.”
“Because the graft is my own skin, there is no chance it won’t ‘take’.”
Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:
Maintain room humidity below 40%
Keep room temperature at 80 degrees
Limit the occurrence of drafts
Place top sheet on the client
While conducting a health assessment with an older adult, the nurse notices it takes the person longer to answer questions than is usual with younger patients. What should the nurse do?
Stop asking questions so as not to confuse the patient.
Ask a family member to answer the questions.
Realize that the patient has some dementia.
Slow the pace and allow extra time for answers.
A teenager states, “Old people are different. They don’t need the same things that young people do.” What is this statement an example of?
ageism
racism
indifference
knowledge
In general, what is the focus of care for nurses who work with older adults?
providing all necessary physical care
assisting patients to function as independently as possible
establishing goals and expected outcomes for the patient
referring patients for needed emotional support
What are the effects of aging on the nervous system?
Accelerated loss of neurons in the brain
Loss of long-term memory
Decreased conduction speed of neurons
Gradually declining loss of intellectual capability
A client with chronic pain reports to you, the charge nurse, that the nurse have not been responding to requests for pain medication. What is your initial action?
Check the MARs and nurses’ notes for the past several days.
Have a conference with the nurses responsible for the care of this client
Perform a complete pain assessment and history on the client.
Ask the nurse educator to give an in-service about pain management.
Family members are encouraging your client to “tough it out” rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the family’s wishes. Priority nursing interventions for this client should target which dimension of pain?
sensory
affective
sociocultural
behavioral
cognitive
In caring for a young child with pain, which assessment tool is the most useful?
Simple description pain intensity scale
McGill-Melzack pain questionnaire
Faces pain-rating scale
0-10 numeric pain scale
In applying the principles of pain treatment, what is the first consideration?
Treatment is based on client goals.
Drug side effects must be prevented and managed.
The client must be believed about perceptions of own pain.
A multidisciplinary approach is needed.
Which route of administration is preferred if immediate analgesia and rapid titration are necessary?
Sublingual
Intravenous (IV)
Patient-controlled analgesia (PCA)
intraspinal
When titrating an analgesic to manage pain, what is the priority goal?
Ensure that the drug is adequate to meet the client’s subjective needs.
Titrate downwards to prevent toxicity.
Titrate upward until the client is pain free.
Administer smallest dose that provides relief with the fewest side effects.
Place the examples of drugs in the order of usage according to the World Health Organization (WHO) analgesic ladder.
a. Morphine, hydromorphone, acetaminophen and lorazepam
b. NSAIDs and corticosteroids
c. Codeine, oxycodone and diphenhydramine
BAC
CAB
BCA
ABC
Which client is at greater risk for respiratory depression while receiving opioids for analgesia?
An elderly chronic pain client with a hip fracture
A child with an arm fracture and cystic fibrosis
A young female client with advanced multiple myeloma
A client with a heroin addiction and back pain
In caring for clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant?
Assist the client with preparation of a sitz bath.
Evaluate relief after applying a cold application.
Coach the client to deep breathe during painful procedures
Monitor the client for signs of discomfort while ambulating
The physician has ordered a placebo for a chronic pain client. You are newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take?
Prepare the medication and hand it to the physician
Contact the charge nurse for advice.
Follow a personal code of ethics and refuse to give it.
Check the hospital policy regarding use of the placebo.
Which route of administration is preferable for administration of daily analgesics (if all body systems are functional)?
IV
IM
Oral
Transdermal
PCA
A first day postoperative client on a PCA pump reports that the pain control is inadequate. What is the first action you should take?
Deliver the bolus dose per standing order.
Assess the pain for location, quality, and intensity.
Try non-pharmacological comfort measures.
Contact the physician to increase the dose.
For a client who is taking aspirin, which laboratory value should be reported to the physician?
Potassium 3.6
hematocrit 41%
PT 14 seconds
BUN 20
Which of the five senses persists until the end
hearing
smell
touch
sight
The home health nurse visits a 40-year-old breast cancer patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (on a 10-point scale). In prioritizing activities for the visit, you would do which of the following first?
Auscultate for breath sounds.
Administer prn pain medication.
Check pressure points for skin breakdown.
Ask family members about patient's dietary intake.
You are visiting with the wife of a patient who is having difficulty making the transition to palliative care for her dying husband. What is the most desirable outcome for the couple?
A. They express hope for a cure.
B. They comply with treatment options.
C. They set additional goals for the future.
D. They acknowledge the symptoms and prognosis.
A patient has been receiving palliative care for the past several weeks in light of her worsening condition after a series of strokes. The caregiver has rung the call bell, stating that the patient "stops breathing for a while, then breathes fast and hard, and then stops again." You recognize that the patient is experiencing
A. Apnea
B. Bradypnea
C. Death rattle
D. Cheyne-Stokes respirations
What is the primary purpose of hospice?
A. Allow patients to die at home.
B. Provide better quality of care than the family can.
C. Coordinate care for dying patients and their families.
D. Provide comfort and support for dying patients and their families.
The nurse is caring for a patient who has been admitted to the hospital while receiving home hospice care. The nurse interprets that the patient has a general prognosis of which of the following?
A. 3 months or less to live
B. 6 months or less to live
C. 12 months or less to live
D. 18 months or less to live
The family attorney informed a patient's adult children and wife that he did not have an advance directive after he suffered a serious stroke. Who is responsible for identifying end-of-life (EOL) measures to be instituted when the patient cannot communicate his or her specific wishes?
D. Physician and nursing staff
C. Wife and adult children
B. Physician and family
A. Notary and attorney
