NUR 2790 Nursing III- Exam 2 Test Questions from chapters 8, 10, 26, 32, 34

Nursing III- Exam 2 Test Questions from chapters 8, 10, 26, 32, 34 1. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. 2. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? You are free to express your feelings; whatever is said here stays here. 3. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (SATA.) A 35-year-old female with severe chest pain: red tag A 60-year-old male with an open fracture with distal pulses: yellow tag 4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select allthat apply.) Hospital incident commander Assumes overall leadership for implementing the emergency plan Triage officer Rapidly evaluates each client to determine priorities for treatment 5. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? Wash your hands upon entering the patient’s room. 6. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by auto-contamination? Change gloves between wound care on different parts of client’s body. 7. A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? You won’t look exactly the same but cosmetic surgery will help. 8. The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? It’s normal to feel some depression 9. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, “Why am I taking this medication?” How should the nurse respond? It helps prevent stomach ulcers, which are common after burns 10. A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? Administer Furosemide (Lasix) 40mg IV push 11. A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? Serum potassium 6.5 12. A nurse cares for a client who has burn injuries. The client’s wife asks, when will his high risk for infection decrease? How should the nurse respond? When all of his burns have closed 13. A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? Administer the prescribed IV morphine sulfate 14. A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? Gather appropriate equipment and prepare for an emergency airway 15. A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? 27% 16. A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? Urine output of 20mL/hr 17. A nurse reviews the following data in the chart of a client with burn injuries: Admission Note: 36- year-old female with bilateral leg burns NKDA-Health history of asthma and seasonal allergies. Wound Assessment: Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0- 10. Based on the data provided, how should the nurse categorize this clients injuries? Full Thick-ness 18. A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (SATA) Administer analgesics, prevent wound infection, provide fluid replacement 19. A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which non- pharmacologic comfort measures should the nurse implement? (SATA) music as a distraction tactile stimulation increasing client control 20. A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (SATA) Ask all family members and visitors to perform hand hygiene before touching client carefully monitor burn wounds when providing each dressing change using aseptic technique and wear gloves when performing wound care 21. An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) 1500mL/hr. Parkland formula: 4 mL/ 90 / 50% BSA = 18,000 mL first 24 hours post burn. Half- first 8 hours after injury, 2nd half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 post burn hours. 22. An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate sh