ATI RN Medical Surgical Proctored Exam Nursing Management for Patients with Burn Injury

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: 1- dislodge the autografts. 2- increase edema in the arms. 3- increase the amount of scarring. 4- decrease circulation to the fingers. 1 Which of the following is a true statement regarding the purposes of skin grafts? 1- Increases evaporative fluid loss. 2- Increases potential for infection. 3- Reduces scarring and contractures. 4- Prolongs recovery 3 The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? 1- Apply ice to the site of the burn for 5 to 10 minutes. 2- Wrap the patients affected extremity in ice until help arrives. 3- Apply an oil-based substance or butter to the burned area until help arrives. 4- Wrap cool towels around the affected extremity intermittently. 4 Which type of burn injury requires skin grafting? 1- Full-thickness 2- Superficial 3- Superficial partial-thickness 4- Deep partial-thickness 1 A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching? 1- "An allograft is a temporary wound covering obtained from cadaver skin." 2- "An allograft is a permanent wound covering taken from a donor site in your body." 3- "An allograft is a temporary wound covering obtained from pig skin." 4- "An allograft is an expensive sheet of skin obtained from a culture." 1 A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? 1- Albumin 2- Dextrose 5% in water (D5W) 3- Lactated Ringer's solution 4- Normal saline solution with 20 mEq of potassium per 1,000 ml 3 A client is brought to the emergency department with partial-thickness and fullthickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 1- 18% 2- 27% 3- 30% 4- 36% 4 Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body? 1- Autograft 2- Allograft 3- Homograft 4- Heterograft 1 A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 1- 18% 2- 27% 3- 36% 4- 45% 2 A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? 1- Superficial 2- Full-thickness 3- Superficial partial-thickness 4- Deep partial-thickness 1 A client has been burned significantly in a workplace accident. Which conditions create the need for intensive care by specifically trained personnel? 1- All options are correct. 2- fluid shift 3- fluid loss 4- hypotension 1 Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? 1- Removal of clothing 2- Irrigation of the wound 3- Application of ice 4- Removal of hair 3 The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies? 1- Hypernatremia 2- Hypokalemia 3- Hyperkalemia 4- Hypercalcemia 3 A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: 1- Epidermal layer only. 2- Epidermis and a portion of deeper dermis. 3- Entire dermis and subcutaneous tissue. 4- Dermis and connective tissue. 2 A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? 1- Hyperactive bowel sounds 2- Decreased peristalsis 3- Fecal occult blood 4- Hematemesis 2 A male patient is brought to the emergency department (ED) from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When the nurse assesses the patient, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's right arm? 1- Superficial partial-thickness 2- Deep partial-thickness 3- Full partial-thickness 4- Full-thickness 4 A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? 1- Full-thickness 2- Superficial 3- Superficial partial-thickness 4- Deep partial-thickness 1 The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? 1- Roll the client in a blanket. 2- Cover the client with a wet cloth. 3- Place the client with the head positioned slightly below the rest of the body. 4- Avoid immediate IV fluid therapy. 1 The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? 1- "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." 2- "I will drink a lot of fluids to prevent constipation since I am taking pain medications." 3- "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." 4- "I can work with the social worker to find funding assistance programs to help with my medical expenses." 3 As the first priority of care, a patient with a burn injury will initially need: 1- a patent airway established. 2- an indwelling catheter inserted. 3- fluids replaced. 4- pain medication administered. 1 In a client with burns on the legs, which nursing intervention helps prevent contractures? 1- Applying knee splints 2- Elevating the foot of the bed 3- Hyperextending the client's palms 4- Performing shoulder range-of-motion exercises 1