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Adult health test 3 Test sobre Burns , creado por Esmeralda Espitia el 09/03/2020.

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Burns

Pregunta 1 de 15

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1. A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply:

Selecciona una o más de las siguientes respuestas posibles:

  • A. Acute kidney injury

  • B. Dysrhythmia

  • C. Iceberg effect

  • D. Hypernatremia

  • E. Bone fractures

  • F. Fluid volume overload

Explicación

Pregunta 2 de 15

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2. True or False: A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather than with an acidic chemical burn.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 3 de 15

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3. As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient’s urine for:

Selecciona una de las siguientes respuestas posibles:

  • A. Hemoglobin and myoglobin

  • B. Free iron and white blood cells

  • C. Protein and red blood cells

  • D. Potassium and Urea

Explicación

Pregunta 4 de 15

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4. Select the patient below who is at MOST risk for complications following a burn:

Selecciona una de las siguientes respuestas posibles:

  • A. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs.

  • B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso.

  • C. A 36 year old male with full-thickness burns on the front of the left arm.

  • D. A 10 year old with superficial burns on the right leg.

Explicación

Pregunta 5 de 15

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5. You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as:

Selecciona una de las siguientes respuestas posibles:

  • A. 1st Degree (superficial)

  • B. 2nd Degree (partial-thickness)

  • C. 3rd Degree (full-thickness)

  • D. 4th Degree (deep full-thickness)

Explicación

Pregunta 6 de 15

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6. A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned?

Selecciona una de las siguientes respuestas posibles:

  • A. 63%

  • B. 81%

  • C. 72%

  • D. 54%

Explicación

Pregunta 7 de 15

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7. A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a:

Selecciona una de las siguientes respuestas posibles:

  • A. 1st degree (superficial) burn

  • B. 2nd degree (partial-thickness) burn

  • C. 3rd degree (full-thickness) burn

  • D. 4th degree (deep full-thickness) burn

Explicación

Pregunta 8 de 15

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8. A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to:

Selecciona una de las siguientes respuestas posibles:

  • A. Prevent hypothermia

  • B. Assess the blood pressure

  • C. Assess the airway

  • D. Prevent infection

Explicación

Pregunta 9 de 15

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9. A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient’s plan of care, which nursing diagnosis is priority at this time?

Selecciona una de las siguientes respuestas posibles:

  • A. Impaired skin integrity

  • B. Risk for fluid volume overload

  • C. Risk for infection

  • D. Ineffective coping

Explicación

Pregunta 10 de 15

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10. The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: select all that apply

Selecciona una o más de las siguientes respuestas posibles:

  • A. Place cold compressions on the burn and elevate the right leg below the heart level

  • B. Assess the distal pulses in the right extremity

  • C. Elevate the right leg above the heart level

  • D. Place gauze securely around the leg to prevent infection

Explicación

Pregunta 11 de 15

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11. A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to:

Selecciona una de las siguientes respuestas posibles:

  • A. Increase the IV fluids

  • B. Continue to monitor the patient

  • C. Decrease the IV fluids

  • D. Notify the physician of this finding

Explicación

Pregunta 12 de 15

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12. A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling’s Ulcer. What signs and symptoms can present with this condition?

Selecciona una de las siguientes respuestas posibles:

  • A. Swelling and pain on the area distal to the burn

  • B. Burning, gnawing sensation pain in the stomach and vomiting

  • C. Dark red or gray sores on the soles of the feet

  • D. Difficulty swallowing and gagging

Explicación

Pregunta 13 de 15

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13. You’re assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene?

Selecciona una de las siguientes respuestas posibles:

  • A. The nursing assistant elevates the head of the bed above 30 degrees.

  • B. The nursing assistant places a pillow under the patient’s head.

  • C. The nursing assistant places rolled towels under the patient’s shoulders.

  • D. The nursing assistant covers the patient with sterile linens.

Explicación

Pregunta 14 de 15

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14. While collecting a medical history on a patient who experienced a severe burn, which statement by the patient’s family member requires nursing intervention?

Selecciona una de las siguientes respuestas posibles:

  • A. “He takes medication for glaucoma”.

  • B. “I think it has been 10 years or more since he had a tetanus shot.”

  • C. “He was told he had COPD last year.”

  • D. “He smokes 2 packs of cigarettes a day.”

Explicación

Pregunta 15 de 15

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15. A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs:

Selecciona una de las siguientes respuestas posibles:

  • A. Oxygen nasal cannula 5-6 Liters

  • B. 100% oxygen via non-rebreather mask

  • C. Continuous Bipap

  • D. Venturi mask 6 L oxygen

Explicación