NUR 265 Exam 3 Questions and Answers Latest Updated 2024/2025 /A+ Graded.

Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action? - Correct Answer -Document the findings Why? Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this Three days after a burn injury, the client develops a temperature of 100° F, white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which - Correct Answer -Wound infection wound to the LPN. Which instruction is most important for the RN to provide the LPN? - Correct Answer -Wash hands upon entering the clients room What intervention will the nurse implement to reduce a client's pain after a burn injury? - Correct Answer -Administer 4mg Morphine IV What statement indicates the client needs further education regarding the skin grafting (allografting)? - Correct Answer -"Because the graft is my own skin, there is no chance it won't 'take.' When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? - Correct Answer -Changing gloves between wound care on different parts of the client's body Which assessment finding assists the nurse in confirming inhalation injury? - Correct Answer -Brassy cough Which finding indicates that fluid resuscitation has been successful for a client with a burn injury? - Correct Answer -Urine output = 50ml/HR Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance? - Correct Answer -Performing his own morning care. Why? Indicators that the client with a burn injury has a positive perception of his appearance includes the willingness to touch the affected body part. Self-care activities such as NUR 265 Exam 3 Questions and Answers Latest Updated 2024/2025 /A+ Graded morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the Which finding indicates to the nurse that the client understands the psychosocial impact of his severe burn injury? - Correct Answer -It is normal to feel depressed. Which finding is characteristic during the emergent period after a deep full thickness burn injury? - Correct Answer -Urine output of 10ml/hr Why? During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreaseD. Foulsmelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns. Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain? - Correct Answer -Decreased tissue perfusion Why? During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury and a disrupted breathing pattern. Disturbed body image and disuse syndrome can develop. However, these are not priority diagnoses at this time. Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report to the physician immediately? - Correct Answer -Serum potassium,7.5 mmol/L (mEq/L) Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury? - Correct Answer -Allowing the client to eat whenever he or she wants Why? Clients should request food whenever they think that they can eat, not just according to the hospital's standard meal schedule. The nurse needs to work with a nutritionist to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications. hich statement best exemplifies the client's understanding of rehabilitation after a fullthickness burn injury? - Correct Answer -"My goal is to achieve the highest level of functioning that I can" Which statement indicates that a client with facial burns understands the need to wear a facial pressure garment? - Correct Answer -"My facial scars will be less with the use of this facial mask" he client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action - Correct Answer -Loosen the dressing During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? - Correct Answer -Increased serum creatinine levels. The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? - Correct Answer -MI 1 year ago A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? - Correct Answer -Learning to perform dressing changes A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? - Correct Answer -Begin IV fluids A client who was burned has crackles and a respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first? - Correct Answer -Place the client in an upright position. Why? Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in the upright position can relieve the lung congestion immediately before other measures can be carried out. Digoxin may be given later to increase cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid. Monitoring urine output is important. However it is not an immediate intervention. How will the nurse position a client with a burn wound to the posterior neck to prevent contractures? - Correct Answer -Have the client turn head from side to side On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action? - Correct Answer -Preparing for intubation Ten hours after the client with 50% burns is admitted, her blood glucose level is 140 mg/dL. What is the nurse's best action? - Correct Answer -Documents the findings The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury? - Correct Answer -Partial thickness-superficial The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a "small amount of pain." How will the nurse categorize this injury? - Correct Answer -Full thickness The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client? - Correct Answer -HR and rhythm The client has severe burns around the right hip. Which position is most important to use to maintain maximum function of this joint? - Correct Answer -Hip at zero flexion with leg flat The client who is burned is drooling and having difficulty swallowing. Which action will the nurse take first - Correct Answer -Auscultates breath sounds over the trachea and mainstem Bronchi The client with a full-thickness burn is being discharged to home after a month in the hospital. His wounds are minimally opened and he will be receiving home care. Which nursing diagnosis has the highest priority? - Correct Answer -Impaired adjustment The client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse's best response? - Correct Answer -This will help prevent stomach ulcers The client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide? - Correct Answer -You will not look exactly the same The client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which is the nurse's best action? - Correct Answer -Preparing to do a work up for sepsis The family of a client who has been burned asks at what point the client will no longer be at greater risk for infection. What is the nurse's best response? - Correct Answer - When the burn wounds are closed The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first? - Correct Answer -Removes loose non-viable tissue The nurse uses topical gentamicin sulfate (Garamycin) on a client's burn injury. Which laboratory value will the nurse monitor? - Correct Answer -Creatinine the client diagnosed with a mild concussion is being discharged from the emergency department. which discharge instruction should the nurse teach the clients significant other? 1. awake in the client every 2 hours. 2. monitor for increased intracranial pressure. 3. observe frequently for hypervigilance. 4. offer the client food every 3 to 4 hours. - Correct Answer -answer 1. Awakening the client every 2 hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety, all signs a post concussion syndrome ,which would warrant a return to the emergency department. he resident in a long term care facility Fell during the previous shift and has a laceration in the occiptal area that has been closed with steri strips. Which signs or symptoms would warrant transferring the resident to the emergency department?1. A 4 centimeters area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that's resolved with medication. - Correct Answer -2. These signs and symptoms indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention