ARE YOU KIDDING ME? BURNS 1. An adults shirt catches on fire and is now in flames.

He panics and runs into his neighbors yard. Which of the following interventions is appropriate? Select all that apply. a. Dousing water. the flames with

3. The nurse is planning care for an adult man who is admitted with severe flame burns. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by a. An increase volume of plasma. in the total intravascular

b. Excessive renal perfusion with dieresis c. Fluid shift from spaces to plasma interstitial

b. Removing his burned clothing. c. Removing his jewelry. d. Rolling him on the ground. ANSWERS: A, C, D RATIONALE: Dousing the flames is an appropriate way to smoother the flames. Removing jewelry should be selected because hot metal jewelry could increase burning. Rings should be removed before edema occurs. Rolling him on the ground can smoother flames. 2. The nurse is caring for a man admitted with severe burns sustained when his clothing caught fire while he was burning leaves. During the acute burns phase, the nurse explains to the man that his nursing care plan is directed toward all of the following except a. Strict aseptic technique b. Proper alignment of all joints c. Maintenance of fluid electrolyte balance and ANSWER: B ANSWER: D

d. Fluid shift from plasma to interstitial spaces

RATIONALE: The initial fluid alteration following a severe burn is a plasma-tointerstitial fluid and electrolyte balance, which is a nursing priority. 4. The nurse is caring for an adult who was admitted following severe burns sustained in a house fire. The nurse understands that an acceptable range for hourly urine output during the first 2 days post-burn is a. 20 ml. b. 30-50ml. c. 100-150ml. d. 150-200 ml.

d. Frequent and routine administration of narcotics ANSWER: D RATIONALE: narcotics should be given only after careful assessment in this phase due to the danger of shock and respiratory depression.

RATIONALE: A safe range for the hourly urine output post-burn us 30 50 ml. Less than this amount would indicate severely decreased renal arterial perfusion. 5. A 78-year-old man is admitted with severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include

a. Strict isolation techniques and policies. b. A semi-private room. c. Liberal unrestricted visiting. d. Equipment shared between the client and the other client in the unit. ANSWER: A RATIONALE: Isolation is thought by some clinicians to reduce the incidence of cross contamination significantly. However, methods vary drastically from one center to another. The single most effective technique to prevent transmission of infection is handwashing. 6. A 23-year-old factory worker was burned severely in an industrial accident. He has second-degree burns on his right leg and arm and on his back. He has third-degree burns on his left arm. The triage nurse, using tje rule of nines, estimates the extent of the clients burns as _______%. a. 58% b. 56% c. 54% d. 55% ANSWER: C RATIONALE: The rule of nine is a quick assessment scale used to estimate the extent of burn injury. The basis of the rule is to divide the body into areas each representing 9% or a multiple of 9% of the total body surface area. The clients injuries were assigned the following percentages: R arm 9%, L arm 9%, R leg 18%, back 18%, total 54% 7. An adult was burned in a house fire 16 hours ago. She suffered second-hand and third-degree burns over 65% of her body. She is receiving lactated Ringers

at 200 ml/h. Which of the following interventions is a priority at this time? a. Monitoring output. hourly urine and

b. Assessing for signs symptoms of infection.

c. Performing range of motion every 1-2 hours. d. Meeting the high caloric needs of the client. ANSWER: A RATIONALE: Urine output is the most readily available and reliable indicator for determining the adequacy of fluid resuscitation. Urine output should be monitored every hour and maintained between 30 and 50 ml/h. 8. A nurse is providing care for a severely burned client during shock phase of the burn injury. Which assessment findings would indicate that the client is receiving adequate fluid volume replacement? a. Urine output 20ml/h, CVP 3, weak pulses, K level of 5.3 b. Urine output 50 ml/h, BP 100/60, oriented to person and place. c. Weak thread pulses, BP 70/40, pulse 130, Hct 52%. d. Restlessness, confusion, urine output 15 ml/h, rapidly increasing weight. ANSWER: B RATIONALE; 50 ml/h of urine output is adequate, BP is stable, clear sensorium is another positive sign that adequate fluid volume replacement is occurring. Pulses should also be easily palpable. 9. A client with severe burns is receiving IV Zantac. Which statement best

explains the reasons for administration of this medication in this situation? a. The client was treated for gastric several years ago. b. The medication will reduce hypoxemia in burn clients. c. The medication is an H2 receptor antagonist and will decrease acid secretion. d. The medication will aid in removal of pulmonary secretions. ANSWER: C RATIONALE: Burn clients are very susceptible to development of stress ulcers. Routinely they receive Zantac to help prevent this complication.

11.A client has suffered chemical burn. The best initial reaction is to a. Roll the client is a blanket. b. Secure lead-lined gloves and move the client away from the chemical c. Flush the area with copious amounts of water or normal saline. d. If the chemical is an acid, neutralize with a base. ANSWER: C RATIONALE: Water will neutralize most chemicals while decreasing the heat reaction. 12.A 25 year-old electrical worker has come in contact with a live power line. He is unconscious and is lying across the power line. The best initial action is to a. Move the person away from the power line using a wooden pole. b. Cover the blanket. person with a

10.An 18-year-old was burned 6 weeks ago. She is now ready for discharge. Select the statement best reflecting understanding of discharge care. a. I will be so glad to get home so that I dont have to wear this pressure thing anymore. b. I will need to call my doctor if my temperature goes up or this burn area starts draining and oozing. c. I really need to stick to a lowcalorie, low-protein diet. d. To prevent that area of new skin from feeling so tight, I can rub ice and baby oil on it. ANSWER: B RATIONALE: This statement demonstrates that the client realizes she must be alert to the signs and symptoms of infection and notify her physician if they do occur.

c. Grab the person and pull him away from the power lines. d. Flush the wound with copious amounts of water. ANSWER: A RATIONALE: Emergency treatment starts with separating the client from the power source. It is important to use nonconductive implements such as wooden poles to prevent injury to the rescuer. 13.Burn injuries occur when energy form a heat source is transferred to the tissues of the body. Which among the following is not a source of burns? a. Inhalation

b. Radiation c. Environment d. Chemical ANSWER: C RATIONALE: Burn injuries are categorized according to mechanism of injury such as thermal burn, chemical burn, electrical burn, radiation burn, inhalation injury. 14.Which of the following situation is not classified under thermal burns as a cause? a. Child playing on the table and accidentally spills over him a hot coffee. b. A 3 year old kid comes in contact with highly concentrated cleaning agent. c. A diabetic patient unknowingly had burn after a foot spa. d. A 25 year-old male involved in an explosive automobile accident. ANSWER: B RATIONALE: This is categorized under chemical burns. Thermal burns are caused by exposure to or contact with flame, hot liquids, semi-liquids (steam), semi-solids (tar), or hot objects. 15.Contact with electrical current of greater than 40 volts is potentially dangerous. Which of the following is considered to be a high-voltage current? a. 700 volts b. 800 volts c. 900 volts d. 1000 volts

ANSWER: D RATIONALE: current greater than 1000 volts is considered to be high-voltage current and is associated with extensive tissue damage. 16.Which among the following considered as radiation burn? a. Trapped in an smoke-filled space b. Sunburn c. Ignition of poorly flammable liquids d. None of the above ANSWER: B RATIONALE: Radiation burns are the least common type of burn injury and are caused by exposure to a radioactive source like nuclear radiation accidents, and therapeutic irradiation. Sunburn, form prolonged exposure to ultraviolent rays (solar radiation), is also considered to be under this type of burn. 17.What is the most common type of burns among toddlers? a. Sunburn b. Chemical injuries c. Scald injuries d. Smoke poisoning ANSWER: C RATIONALE: Scald injuries are frequently the result of mishaps in the performance of everyday tasks such as bathing and cooking. Overturned coffeepots, cooking pans spilling hot liquid and grease, overheated foods, liquids cooked in microwave ovens, and hot tap water. 18.What is the most common type of burns among young adult? a. Sunburn stored is

enclosed,

b. Chemical injuries c. Electrical injuries d. Flash burns ANSWER: D RATIONALE: Direct contact with flame in the young adult is the second leading cause of burn injury. 19.A community health nurse is educating the resident to prevent home burn injuries. All are included in the teaching plan except: a. Purchase a stove with controls on the front or side to reduce likelihood of clothing ignition as one reaches the hot elements. b. Place a screen around any heating appliance to function as barrier. c. Turn pot handles toward the back of the stove. d. Adjust the thermostat setting on the water heater to produce a temperature no higher than 50 degree Celsius. ANSWER: D RATIONALE: Legislation recommends a water temperature of no longer than 48.8 degree celsius (120F) to prevent scald injuries. 20.Depending on the skin layers damaged and degree of burns. Which of the following perfectly describe seconddegree partial thickness burns? a. Superficial, painful and appear red. b. Appear wet or blistered and are extremely painful c. Dry and may be black ANSWER: B ANSWER: B

d. Charred and burned away.

completely

RATIONALE: A is first-degree partial thickness burn. C is third degree full-thickness burn and D is fourth degree full-thickness burn. 21.A urinalysis test result of a burned patient reveals dark amber color, specific gravity of 1.030 and an elevated BUN levels in blood test indicates that he/she is ______? a. Infected b. Dehydrated c. Immuno compromised d. Uremic

RATIONALE: The characterics perfectly describe dehydration.

mentioned

22. During the assessment of a patient who had severe burns thorax and abdomen, the nurse expects to notice which of the following? a. Decreased urine output, edema hypersensitivity on affected area, and crackles on lung fields. b. Altered body temperature, hypoventilation, crackles on lung fields and absent bowel sounds c. Diuresis, edema and numbness on affected area, and absent bowel sounds d. Dyspnea, edema affecting both burned and non-burned tissues, altered level of consciousness, and weak peripheral pulses.

ANSWER: D RATIONALE: Dyspnea is a result of airway obstruction due to edema of the airways. General edema affecting both burned and non-burned tissues is a result of extensive burn (greater than 25% TSBA). Alteration in the level of consciousness is merely because of poor cerebral perfusion and weak peripheral pulses is an indicator of decreased cardiac output and circulating blood volume. 23.Courses of healing in burned patient depend on the degree of injury. A patient who obtained a 3rd degree fullthickness burn requires; a. Autografting for healing b. Amputation extremities of affected

c. It is acute and high intensity pain that is experienced during the performance of therapeutic measures. d. It is a severely acute pain.

ANSWER: A RATIONALE: A is a type of pain that includes non-procedure-related activities. C is known as procedural pain experienced during performance of therapeutic measures commonly used in burn care. B is not a type of pain experienced by burned patient and D is a description of procedural pain.

c. Desquamation in 3-7 days d. Greater healing ANSWER: A RATIONALE: Autograft is advisable for 3rd degree full thickness burn. Amputation of extremity is only recommended for 4th degree full thickness burn. Desquamation of skin in 37 days occurs in 1st degree partial thickness burn. 2nd degree Deep partial-thickness burn requires greater than 21 days of healing. 24.The client experiences substantial pain as a result of burn wound and exposed nerve endings from lack of skin integrity. Which of the following best describe the background pain exhibit by burned patients? a. It is experienced when the client is at rest, shifting from one position to the other, and coughing. b. It is a type of pain that is radiating to the unaffected area. than 21 days for

25.A 32 year-old female was severely burned after an explosive vehicular accident. Which of the following is a priority action to save the life of the victim? a. Start an rehydration. IV line for

b. Loose or cut tight clothing that will hinder airway patency. c. Administer narcotics to free the patient from pain. d. Remove the victim from the area of immediate danger. ANSWER: D RATIONALE: Management of the burn client begins at the scene of the accident. The first step should be to remove the victim from the area of immediate danger, followed by stopping the burning process. Basic life support measures should be implemented during transport of the client to the hospital.

26.It consists the time between the initial injury and 36 to 48 hours after injury.

This phase ends when resuscitation is complete. a. Emergent phase b. Acute phase c. Chronic phase d. Reparatory phase ANSWER: A

fluid

priority consideration when initiating the treatment for this client? a. Strict aseptic needed. technique is

b. Pulmonary complications are frequent c. Requires intense physical and occupational therapy d. Distal vascular compromise is possible

27.It is the phase of recovery following a major burn begins when the client is hemodynamically stable, capillary restored, and dieresis has begun. This is generally 48 to 72 hours after the time of injury. a. Reparatory phase b. Rehabilitation phase c. Acute phase d. Homeostatic phase ANSWER: C 28.It is final phase of burn care and encompasses the time from wound closure to discharge and beyond. a. Restoration phase b. Rehabilitation phase c. Acute phase d. Homeostatic phase ANSWER: B

ANSWER: B RATIONALE: A is a universal protocol for all burn patients regardless of what area is affected. C is management of burns of the hands and joints. D is a concern for a patient with circumferential burns of extremities.

30.During health history taking of a burned client, the nurse becomes more concern upon getting which of the following data from the client? a. Patient is alcoholic b. Patient lives in a squatter area c. Patient is 30 years old d. Patient lives alone

ANSWER: A RATIONALE: Alcoholic clients with burn injury have a threefold increase in mortality rate over that of non-alcoholic client with burns. They have longer hospital stay and acquire more complications. This may be related to impaired immune function.

RATIONALE: Three distinct periods or phases of treatment can be defined in the care of seriously burned client: the emergent, the acute, and the rehabilitation phases.

29.A burned client obtains severe burns on head, neck and chest. What is the

31.To prevent burn shock fluid resuscitation is generally required. Starting an IV line is definitely life

saving. Which of the following is least helpful in rehydration a. Two peripheral large-bore IV lines are should be placed through non-burned skin. b. IV lines cannot be placed in burned skin. c. Cannulation of a central vein can be established in extensive burns or limited peripheral IV access sites. d. Subclavian vein is one of the access site for intravenous line. ANSWER: B RATIONALE: IV lines may be placed in burned skin, if necessary; however, these lines should be secured with a suture.

33.During rehydration, it is important that the nurse; a. Monitor patients breath sounds to determine over hydration. b. Weigh the patient daily c. Check for peripheral pulses and presence of edema d. Place an indwelling urethral catheter with a draining bag.

ANSWER: D RATIONALE: An indwelling urethral catheter connected to a closed drainage system should be placed to measure hourly urine production and to guide IV fluid replacement.

32.During the first 24 hours of fluid management what type of solution would be infused a. Lactated Ringer`s b. Colloid-containing solutions c. 5% dextrose d. Albumin

34.Select all the baseline laboratory studies to be done for burned client. a. Blood glucose b. BUN c. Serum creatinine d. ABG e. Serum electrolytes f. Urinalysis

ANSWER: A RATIONALE: During the first 24 hours after burn injury generally includes the infusion of balanced salt solution, typically lactated Ringer`s solution. Colloid-containing solutions are not given during this period because of the changes in capillary integrity that allow leakage of protein-rich fluid. During the second 24 hours after burn injury, along with 5% dextrose and water in colloid-containing solutions are administered.

g. Hematocrit h. PTT i. Platelet count

ANSWER: A TO G

SURGERY

35.An adult man is in the postanesthesia care unit (PACU) following hemilectomy. How often will the nurse monitor the vital signs? a. Continuously b. Every 5 minutes c. Every 15 minutes d. On a prn basis ANSWER: C RATIONALE: When in the postanesthesia care unit (PACU) the clients vital signs are assessed every 15 minutes.

RATIONALE: Evisceration is the actual intestinal contents protruding through the abdominal wall. 38.An adult clients wound has eviscerated. Why would the respiratory status need to be assessed? a. Dehiscence diaphragm elevates the

b. Coughing increases intestine protrusion c. Respiratory arrest commonly accompanies wound dehiscence d. Splinting the wound will compromise the respiratory status ANSWER: B RATIONALE: Coughing increases intraabdominal pressure, which could force loops of bowel out trhough the open wound. 39.An adult client has acute leukemia and is scheduled for a Hickman catheter insertion under local anesthesia. What is a major advantage to the client for having regional anesthesia? a. Retains all reflexes b. Remains conscious c. Has retroactive amnesia d. Is in the OP for a short period of time. ANSWER: B RATIONALE: the client receiving regional anesthesia has nerve impulses blocked but does not lose consciousness. 40.An adult male is scheduled for surgery and the nurse is assessing for risk factors. Which of the following are the greatest risk factors?

36.An adult who has had general anesthesia for major surgery is in the PACU. Which of the following indicates the artificial airway should be removed? a. Gagging b. Restlessness c. An increase in pain d. Clear lungs on auscultation ANSWER: A RATIONALE: The return if the gag reflex usually indicates that the client is able to manage his own secretions and maintain a patent airway. 37.An adult is 6 days post abdominal surgery is in the PACU. Which sign alerts the nurse to wound evisceration? a. Acute bleeding b. Protruding intestines c. Purple drainage d. Severe pain ANSWER: B

a. He is 5 ft 4 inches tall and weighs 125 lbs b. He expresses a fear of pain in the post-op period. c. He is 5 ft 4 in tall, weighs 360 lbs, and has diabetes. d. He expresses a fear of the unknown. ANSWER: C RATIONALE: Obesity and diabetes are major risk factors with the potential for complications related to anesthesia. 41.The nurse enters a womans room to administer the ordered pre-op medication for hysterectomy. During the conversation, the client tells the nurse that she and her husband are planning to have another child in the coming year. The best action for the nurse to take is which of the following? a. Do not administer the pre-op medication, notify the nursing supervisor and the physician. b. Go ahead and administer the medication as ordered. c. Check to see if the client has signed a surgical consent d. Send the client to the operating room (OPR) without the medication. ANSWER: A RATIONALE: No client should be administered the pre-op medication until the informed consent has been obtained. Informed consent means that the client understands the information about the surgery. Even if the consent form is signed, the nurse should with hold sedating medication. This client clearly does not understand the planned procedure. 42.The nurse in an outclient department is interviewing an adult 1 week prior to

her scheduled elective surgery. In planning for the surgery, which of the following should the nurse include in her teaching? a. Detailed information the procedure about

b. Limitations of oral intake the day of the procedure c. Writing a list for postoperative complications d. The client should not take any of her routine medications the morning of the surgery. ANSWER: B RATIONALE: Instructions should be given to the client regarding limitation of oral intake to avoid nausea and vomiting from the anesthesia. 43.The nurse administers 10 mg intramuscular (IM) morphine as a pre-op medication, and then discovers that there is no signed operative permit. What is the best action for the nurse to take? a. Send the client to surgery as scheduled. b. Notify the nursing supervisor, the OR, and the physician c. Cancel the immediately surgery

d. Obtain the needed consent ANSWER: B RATIONALE: If a narcotic, sedative, or tranquilizers drug has been administered before signing of the consent, the drug`s effects must be allowed to wear off before consent can be given. 44.An adult received