ATI RN Burn Care & Emergency Nursing Quiz: Airway, Fluid Resuscitation, GI Bleed, Snake Bite

Detailed Answer Key
RN 231 Quiz 4_Cloned_Assessment 1



1. A h,nurse h,is h,caring h,for h,a h,client h,admitted h,to h,the h,emergency h,department h,with h,extensive h,partial h,and h,full-
thickness h,burns h,of h,the h,head, h,neck, h,and h,chest. h,While h,planning h,the h,client's h,care, h,the h,nurse h,should h,be h,aware
h,that h,initially h,the h,client h,is h,at h,greatest h,risk h,for



A. airway obstruction.
Rationale: h,Burns h,of h,the h,head, h,neck, h,and h,chest h,may h,involve h,damage h,to h,the h,pulmonary h,tree h,due
h, to h,heat h,as h,well h,as h,smoke h,and h,soot h,inhalation. h,This h,can h,result h,in h,severe h,respiratory h,difficulty. h,Nursing
measures h,to h,maintain h,a h,patent h,airway h,should h,take h,priority h,in h,this h,client's h,care. h,B. h,infection.
h,


Rationale: h,Although h,prevention h,of h,infection h,is h,an h,important h,aspect h,of h,burn h,care h,throughout
h, hospitalization h,and h,treatment, h,there h,is h,a h,greater h,initial h,priority h,for h,this h,client. h,C. h,fluid h,imbalance.
Rationale: h,Although h,adequate h,fluid h,replacement h,is h,an h,important h,aspect h,of h,burn h,care h,throughout h,the
h, acute h,phase h,of h,burn h,treatment, h,there h,is h,a h,greater h,initial h,priority h,for h,this h,client. h,D. h,paralytic h,ileus.
Rationale: h,Although h,paralytic h,ileus h,may h,occur h,during h,the h,acute h,phase h,aspect h,of h,burn h,care h,and
h,may h,require h,nasogastric h,suctioning, h,there h,is h,a h,greater h,initial h,priority h,for h,this h,client.




2. h,A h,nurse h,in h,a h,burn h,treatment h,center h,is h,caring h,for h,a h,client h,who h,is h,admitted h,with h,severe h,burns h,to h,both h,lower
h,extremities h,and h,is h,pending h,an h,escharotomy. h,The h,client's h,spouse h,asks h,the h,nurse h, what h,the h,procedure

h,entails. h,Which h,of h,the h,following h,nursing h,statements h,is h,appropriate?



A. "Large incisions will be made in the eschar to improve circulation."
Rationale: h,An h,escharotomy h,is h,a h,surgical h,incision h,made h,to h,release h,pressure h,and h,improve h,circulation
h,in h,a h,part h,of h,the h,body h,that h,has h,a h,deep h,burn h,and h,is h,experiencing h,excessive h,swelling.

h,Burn h,injuries h,that h,encircle h,a h,body h,part, h,such h,as h,an h,arm h,or h,the h,chest, h,can h,cause

h,swelling h,and h,tightness h,in h,the h,affected h,area, h,resulting h,in h,reduced h,circulation. h,Making

h,surgical h,incisions h,into h,the h,burned h,tissue h,allows h,the h,skin h,to h,expand, h,reduces h,tightness

h,and h,pressure, h,and h,improves h,circulation.



B. h , "I h,can h,call h,the h,doctor h,back h,here h,if h,you h,want h,me h,to."
Rationale: h,This h,is h,a h,nontherapeutic h,response h,that h,defers h,the h,client's h,concern h,and h,puts h,it h,on h,hold.
C. h, "A h,piece h,of h,skin h,will h,be h,removed h,and h,grafted h,over h,the h,burned h,area."
Rationale: h,A h,surgical h,procedure h,in h,which h,a h,piece h,of h,skin h,from h,one h,area h,of h,the h,client's h,body h,is
h,transplanted h,to h,another h,area h,is h,called h,a h,skin h,graft.



D. h, "Dead h,tissue h,will h,be h,surgically h,removed."
Rationale: h,Debridement h,is h,the h,surgical h,removal h,of h,dead h,tissue.




3. h,A h,group h,of h,college h,students h,was h,attending h,a h,weekend h,football h,rally h,when h,one h,of h,the h,students h,stumbled
h,and h,fell h,into h,the h,bonfire. h,Although h,several h,friends h, quickly h,intervened, h,the h,client h,sustained h,partial-thickness

h,burns h,to h,both h,lower

,Detailed Answer Key
RN 231 Quiz 4_Cloned_Assessment 1




legs, h,chest, h,and h,both h,forearms. h,Which h,of h,the h,following h,is h,the h,priority h,nursing h,action h,when h,the h,client h,is
h,brought h,into h,the h,emergency h,room?



A. Cover h,the h,burned h,area h,with h,sterile h,gauze.
Rationale: h,Infection h,is h,one h,of h,the h,leading h,causes h,of h,death h,with h,burn h,injuries. h,Because h,the
h,integrity h,of h,the h,skin h,is h,breeched, h,it h,is h,vital h,to h,cover h,all h,burned h,areas h,with h,sterile

h,gauze; h,however, h,this h,is h,not h,the h,priority h,concern h,at h,this h,time.



B. Inspect mouth for signs of inhalation injuries.
Rationale: h,Since h,the h,client h,sustained h,burns h,to h,the h,chest, h,there h,is h,a h,possibility h,that h,flames h,and
h,smoke h,from h,the h,client's h,burning h,clothes h,could h,have h,caused h,an h,inhalation h,injury. h,The

h,nurse h,should h,inspect h,the

mouth h,and h,throat h,for h,soot h,and h,swelling. h,Using h,the h,airway, h,breathing, h,circulation h,(ABC) h,priority-setting
h,framework, h,this h,is h,the h,priority h,concern h,at h,this h,time. h,C. h,Administer h,intravenous h,pain h,medication.


Rationale: h,Because h,of h,the h,large h,percentage h,of h,burned h,area, h,this h,client h,will h,experience h,high
h,levels h,of h,pain, h,since h,partial-thickness h,burns h,expose h,fragile h,nerve h,endings. h,Large h,doses h,of
h,intravenous h,morphine h,or h,other h,narcotic h,analgesics h,will h,likely h,be h,needed h,for h,adequate h,pain h,control.

h,Despite h,the h,fact h,that h,pain h,is h,an h,important h,issue, h,it h,is h,not h,the h,priority h,concern h,at h,this h,time. h,D. h,Draw

h,blood h,for h,a h,complete h,blood h,cell h,(CBC) h,count.


Rationale: h,Burn h,injuries, h,such h,as h,this h,one, h,that h,exceed h,20% h,of h,body h,surface h,area h,are h,considered
h,major h,burns, h,which h,affect h,the h,client’s h,metabolism, h,hemodynamic h,balance, h,and h,immune

h,system. h,In h,the h,early h,stage h,of h,burns, h,increased h,capillary h,permeability h,allows h,sodium h,to

h,enter h,cells h,while

potassium h,leaks h,out, h,resulting h,in h,hyponatremia h,and h,hyperkalemia. h,An h,altered h,osmotic
h,gradient h,and h,loss h,of h,intravascular h,fluid h,causes h,elevated h,hematocrit h,levels. h,Initial h,lab

h,studies h,are h,important h,to h,create h,a h,baseline h,because h,of h,these h,systemic h,effects h,of h,burns.

h,Those h,labs h, would h,include h,a h,CBC, h,electrolytes, h,BUN, h,creatinine, h,and h,blood h,glucose.

h,While h,it h,is h,important h,to h,establish h,baseline h,data, h,it h,is h,not h,the h,priority h,concern h,at h,this h,time.




4. h,A h,nurse h,in h,an h,emergency h,department h,is h,caring h,for h,a h,client h,who h,has h,burns h,on h,the h,front h,and h,back h,of h,both
h,his h,legs h,and h,arms. h,Using h,the h,rule h,of h,nines h,the h,nurse h, should h,document h,burns h,to h,which h,percentage h,of h,the

h,client’s h,total h,body h,surface h,area h,(TBSA)?



A. 9 h,percent

Rationale: h,Each h,arm h,represents h,9% h,of h,the h,client’s h,TBSA.
B. 18 h,percent

, Detailed Answer Key
RN 231 Quiz 4_Cloned_Assessment 1
Rationale: h,Each h,leg h,represents h,18% h,of h,the h,client’s h,TBSA.