NUR417 Exam 3 Questions With Complete Solutions
A patient who has burns on the arms, legs, and chest from a
house fire has become agitated and restless 8 hours after being
admitted to the hospital. Which action should the nurse take
first?
a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check oxygen saturation.
ANS: D
Agitation in a patient who may have suffered inhalation injury
might indicate hypoxia, and this should be assessed by the nurse
first. Administration of morphine may be indicated if the nurse
determines that the agitation is caused by pain. Assessing level
of consciousness and orientation is also appropriate but not as
essential as determining whether the patient is hypoxemic.
Reassurance is not helpful to reduce agitation in a hypoxemic
patient.
DIF: Cognitive Level: Analyze (analysis)
A patient arrives in the emergency department with facial and
chest burns caused by a house fire. Which action should the
nurse take first?
a. Auscultate the patient's lung sounds.
b. Determine the extent and depth of the burns.
,c. Give the prescribed hydromorphone (Dilaudid).
d. Infuse the prescribed lactated Ringer's solution.
ANS: A
A patient with facial and chest burns is at risk for inhalation
injury and assessment of airway and breathing is the priority.
The other actions will be completed after airway management is
assured.
DIF: Cognitive Level: Analyze (analysis)
A patient with extensive electrical burn injuries is admitted to
the emergency department. Which prescribed intervention
should the nurse implement first?
a. Assess pain level. c. Check potassium level.
b. Place on heart monitor. d. Assess oral temperature.
ANS: B
After an electrical burn, the patient is at risk for life-threatening
dysrhythmias and should be placed on a heart monitor.
Assessing the oral temperature and pain is not as important as
assessing for cardiac dysrhythmias. Checking the potassium
level is important, but it will take time before the laboratory
results are back. The first intervention is to place the patient on a
heart monitor and assess for dysrhythmias so that they can be
monitored and treated if necessary.
DIF: Cognitive Level: Analyze (analysis)
Eight hours after a thermal burn covering 50% of a patient's total
body surface area (TBSA), the nurse assesses the patient. The
,patient weighs 92 kg (202.4 lb). Which information would be a
priority to communicate to the health care provider?
a. Blood pressure is 95/48 per arterial line.
b. Urine output of 41 mL over past 2 hours.
c. Serous exudate is leaking from the burns.
d. Heart monitor shows sinus tachycardia of 108.
ANS: B
The urine output should be at least 0.5 to 1.0 mL/kg/hr during
the emergent phase, when the patient is at great risk for
hypovolemic shock. The nurse should notify the health care
provider because a higher IV fluid rate is needed. BP during the
emergent phase should be greater than 90 mm Hg systolic and
the pulse rate should be less than 120 beats/min. Serous exudate
from the burns is expected during the emergent phase.
DIF: Cognitive Level: Analyze (analysis)
Which patient should the nurse assess first?
a. A patient with burns who is complaining of level 8 (0 to 10
scale) pain
b. A patient with smoke inhalation who has wheezes and altered
mental status
c. A patient with full-thickness leg burns who is scheduled for a
dressing change
d. A patient with partial thickness burns who is receiving IV
fluids at 500 mL/hr
ANS: B
This patient has evidence of lower airway injury and hypoxemia,
, and should be assessed immediately to determine the need for
O2 or intubation (or both). The other patients should also be
assessed as rapidly as possible, but they do not have evidence of
life-threatening complications.
DIF: Cognitive Level: Analyze (analysis)
Which patient is most appropriate for the burn unit charge nurse
to assign to a registered nurse (RN) who has floated from the
hospital medical unit?
a. A patient who has twice-daily burn debridements to partial-
thickness facial burns
b. A patient who has just returned from having a cultured
epithelial autograft to the chest
c. A patient who has a weight loss of 15% from admission and
will have enteral feedings started
d. A patient who has blebs under an autograft on the thigh and
has an order for bleb aspiration
ANS: C
An RN from a medical unit would be familiar with malnutrition
and with administration and evaluation of response to enteral
feedings. The other patients require burn assessment and care
that is more appropriate for staff who regularly care for burned
patients.
DIF: Cognitive Level: Analyze (analysis)
A patient who was found unconscious in a burning house is
brought to the emergency department by ambulance. The nurse
A patient who has burns on the arms, legs, and chest from a
house fire has become agitated and restless 8 hours after being
admitted to the hospital. Which action should the nurse take
first?
a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check oxygen saturation.
ANS: D
Agitation in a patient who may have suffered inhalation injury
might indicate hypoxia, and this should be assessed by the nurse
first. Administration of morphine may be indicated if the nurse
determines that the agitation is caused by pain. Assessing level
of consciousness and orientation is also appropriate but not as
essential as determining whether the patient is hypoxemic.
Reassurance is not helpful to reduce agitation in a hypoxemic
patient.
DIF: Cognitive Level: Analyze (analysis)
A patient arrives in the emergency department with facial and
chest burns caused by a house fire. Which action should the
nurse take first?
a. Auscultate the patient's lung sounds.
b. Determine the extent and depth of the burns.
,c. Give the prescribed hydromorphone (Dilaudid).
d. Infuse the prescribed lactated Ringer's solution.
ANS: A
A patient with facial and chest burns is at risk for inhalation
injury and assessment of airway and breathing is the priority.
The other actions will be completed after airway management is
assured.
DIF: Cognitive Level: Analyze (analysis)
A patient with extensive electrical burn injuries is admitted to
the emergency department. Which prescribed intervention
should the nurse implement first?
a. Assess pain level. c. Check potassium level.
b. Place on heart monitor. d. Assess oral temperature.
ANS: B
After an electrical burn, the patient is at risk for life-threatening
dysrhythmias and should be placed on a heart monitor.
Assessing the oral temperature and pain is not as important as
assessing for cardiac dysrhythmias. Checking the potassium
level is important, but it will take time before the laboratory
results are back. The first intervention is to place the patient on a
heart monitor and assess for dysrhythmias so that they can be
monitored and treated if necessary.
DIF: Cognitive Level: Analyze (analysis)
Eight hours after a thermal burn covering 50% of a patient's total
body surface area (TBSA), the nurse assesses the patient. The
,patient weighs 92 kg (202.4 lb). Which information would be a
priority to communicate to the health care provider?
a. Blood pressure is 95/48 per arterial line.
b. Urine output of 41 mL over past 2 hours.
c. Serous exudate is leaking from the burns.
d. Heart monitor shows sinus tachycardia of 108.
ANS: B
The urine output should be at least 0.5 to 1.0 mL/kg/hr during
the emergent phase, when the patient is at great risk for
hypovolemic shock. The nurse should notify the health care
provider because a higher IV fluid rate is needed. BP during the
emergent phase should be greater than 90 mm Hg systolic and
the pulse rate should be less than 120 beats/min. Serous exudate
from the burns is expected during the emergent phase.
DIF: Cognitive Level: Analyze (analysis)
Which patient should the nurse assess first?
a. A patient with burns who is complaining of level 8 (0 to 10
scale) pain
b. A patient with smoke inhalation who has wheezes and altered
mental status
c. A patient with full-thickness leg burns who is scheduled for a
dressing change
d. A patient with partial thickness burns who is receiving IV
fluids at 500 mL/hr
ANS: B
This patient has evidence of lower airway injury and hypoxemia,
, and should be assessed immediately to determine the need for
O2 or intubation (or both). The other patients should also be
assessed as rapidly as possible, but they do not have evidence of
life-threatening complications.
DIF: Cognitive Level: Analyze (analysis)
Which patient is most appropriate for the burn unit charge nurse
to assign to a registered nurse (RN) who has floated from the
hospital medical unit?
a. A patient who has twice-daily burn debridements to partial-
thickness facial burns
b. A patient who has just returned from having a cultured
epithelial autograft to the chest
c. A patient who has a weight loss of 15% from admission and
will have enteral feedings started
d. A patient who has blebs under an autograft on the thigh and
has an order for bleb aspiration
ANS: C
An RN from a medical unit would be familiar with malnutrition
and with administration and evaluation of response to enteral
feedings. The other patients require burn assessment and care
that is more appropriate for staff who regularly care for burned
patients.
DIF: Cognitive Level: Analyze (analysis)
A patient who was found unconscious in a burning house is
brought to the emergency department by ambulance. The nurse
