Burns
A client sustained burns on the back. These areas appear dry, blotchy, cherry red, blistering, does not blanch, no capillary refill and reduced or absent sensation. This type of burn depth is classified as?
A. Partial thickness superficial
B. Partial thickness deep
C. Full Thickness
B. Partial thickness Deep
A client is to undergo an escharotomy. Which of the following statements made by the nurse is true regarding this procedure?
A. It is the surgical removal of a thin layer of the client's own unburned skin.
B. A lengthwise incision is made through the burn eschar to relieve vasoconstriction.
C. It is the application of topical enzyme agents directly to the wound and these agents help digest necrotic collagen tissue.
B. A lengthwise incision is made through the burn eschar to relieve vasoconstriction.
Which finding indicates that fluid resuscitation has been successful for a client with a burn injury?
A. HCT 60%
B. HR 130 bpm
C. Increase peripheral edema
D. Urine output is 50 mL/hr.
D. Urine output is 50 mL/hr.
A friend asks you if they should take antibiotics to help get rid of their shingles. You tell them:
A. what do I look like, a doctor?
B. A hammer would probably work better.
C. Yes, they would work fine as shingles are a bacterial infection.
D. No because shingles are a virus.
D. No because shingles are a virus.
Rehabilitation is the final phase of the burn care. Which of the following are the goals during this phase?
A. Provide emotional support
B. Prevent hypovolemic shock
C. Promote wound healing and proper nutrition.
D. Fluid replacement
E. Help the client in gaining optimal physical functioning.
A. Provide emotional support
C. Promote wound healing and proper nutrition.
E. Help the client in gaining optimal physical functioning.
During a full body skin assessment of a patient you see the following lesion with these characteristics: waxy border, red papule with a central crater. This describes what type of lesion?
A. Basal cell
B. Squamous cell
C. melanoma
D. Normal, benign mole
A. Basal cell
Nurse Malcolm is performing a sterile dressing change on a client with a superficial partial thickness burn on the shoulder and back. Arrange the steps in the order in which each should be performed:
1. Cover the wound using a sterile gauze dressing.
2. Administer Tramadol (Ultram) 50 mg IV
3. Debride the wound of eschar using gauze sponges.
4. Apply silver nitrate ointment
5. Obtain sample for wound culture.
A) 2,5,4,3,1
B) 2,3,5,4,1
C) 5,2,3,1,4
D) 5,4,3,1,2
B) 2,3,5,4,1
The evening nurse reviews the nursing ocumentation in the male client's chart and notes that te day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse epect to note on assessment of the client's sacral area?
A. Intact skin
B. Full-thickness skin loss
C. Exposed bone, tendon or muscle
D. Partial-thickness skin loss of the dermis
D. Partial-thickness skin loss of the dermis
Three days after a burn injury, the client develops a temp of 100 degrees, white blood cell count of 15,000, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition?
A. Acute phase of injury
B. Autodigestion of collagen
C. Granulation of burned tissue
D. Wound infection
D. Wound infection
A patient states they are having intense itching between their fingers with brown linear lines presenting. Based on your nursing knowledge, this best describes what condition?
A. Scabies
B. Psoriasis
C. Eczema
D. Ringworm
A. Scabies
The newly admitted client has burns on B 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?
a. Partial thickness superficial
b. Partial thickness deep
c. Full thickness
c. Full thickness
The nurse explains to the family that a family member needs to have an escharotomy. The nurse includes which of the following statements in the explanation?
A. It is only done on extremities
B. It is done to prevent ischemia and necrosis
C. It is done to promote drainag of edema fluid
D. It is exactly the sae as a fasciotomy.
B. It is done to prevent ischemia and necrosis
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action?
A. Administer a laxative
B. Document the findings and notify physician
C. Increase the IV flow rate
D. Reposition the client onto the right side.
B. Document the findings and notify physician
A female client exhibits a purplish bruise to the skin after a fall. The nurse would document most accurately using which of the following terms?
A. Purpura
B. Petechiae
C. Ecchymosis
D. Erythema
C. Ecchymosis
On admission to the emergency department the burned client's blood pressure is 90/60, apical pulse rate of 122. These findings are an expected result of what thermal injury-related response?
A. shock
B. Intense pain
C. Carbon monoxide poisoning
A. shock
A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complains of pain and pruritis. Why would the nurse use a Woods lamp?
A. To dry out the lesions
B. To reduce the pruritus
C. To kill the fungus
D. To cause Fluorescence of the infected hairs.
D. To cause Fluorescence of the infected hairs.
Which assessment finding assists the nurse in confirming inhalation injury?
A. Stridor
B. Decreased BP
C. Nausea
D. Headache
A. Stridor
The nurse is assigned to care for a female client with herpes zoster. Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection?
A. Clustered sin vesicles
B. A generalized body rash
C. Small blue-white spots with a red base
A fiery red, edematous rash on the cheeks.
A. Clustered sin vesicles
What is the term for an infected hair follicle?
A. Folliculitis
B. A furuncle
C. A carbuncle
D. A felon
A. Folliculitis
The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?
A. Immediately before swimming
B. five minutes before exposure to the sun
C. Immediately before exposure t the sun
D. At least 30 minutes before exposure to the sun
D. At least 30 minutes before exposure to the sun