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Chapter 26 exam 3 Burns Shock
test bank
Nur Med Surg (Galen College of Nursing)
Chapter 26
1. 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?
a. Administer the prescribed tetanus toxoid vaccine.
b. Assess the clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients room.
ANS: D
Infection can occur when microorganisms from another person or from the
environment are transferred to the client. Although all of the interventions listed can
help reduce the risk for infection, handwashing is the most effective technique for
preventing infection transmission.
DIF: Applying/Application REF: 466
KEY: Infection control| Standard Precautions| collaboration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
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2. The nurse is caring for a client with an acute burn injury. Which action should the
nurse take to prevent infection by autocontamination?
a. Use a disposable blood pressure cuff to avoid sharing with other clients
b. Change gloves between wound care on different parts of the clients bo
c. Use the closed method of burn wound management for all wound care
d. Advocate for proper and consistent handwashing by all members of th
ANS: B
Autocontamination is the transfer of microorganisms from one area to another area
of the same clients body, causing infection of a previously uninfected area.
Although all techniques listed can help reduce the risk for infection, only changing
gloves between performing wound care on different parts of the clients body can
prevent autocontamination. DIF: Applying/Application REF: 485
KEY: Infection control| Standard Precautions
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment:
Safety and Infection Control
3. The nurse teaches burn prevention to a community group. Which statement by a
member of the group should cause the nurse the greatest concern?
a. I get my chimney swept every other year.
b. My hot water heater is set at 120 degrees.
c. Sometimes I wake up at night and smoke.
d. I use a space heater when it gets below zero.
ANS: C
House fires are a common occurrence and often lead to serious injury or death. The
nurse should be most concerned about a person who wakes up at night and smokes.
The nurse needs to question this person about whether he or she gets out of bed to
do so, or if this person stays in bed, which could lead to falling back asleep with a
lighted cigarette. Although it is recommended to have chimneys swept every year,
skipping a year does not pose as much danger as smoking in bed, particularly if the
person does not burn wood frequently. Water heaters should be set below 140 F.
Space heaters should be used with caution, and the nurse may want to ensure that
the person does not allow it to get near clothing or bedding.
DIF: Applying/Application REF: 472
KEY: Safety| smoking cessation MSC: Integrated Process:
Teaching/Learning
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NOT: Client Needs Category: Health Promotion and Maintenance 4. A nurse cares
for a client who has facial burns. The client asks, Will I ever look the same? How
should the nurse respond?
a. With reconstructive surgery, you can look the same.
b. We can remove the scars with the use of a pressure dressing.
c. You will not look exactly the same but cosmetic surgery will help.
d. You shouldnt start worrying about your appearance right now.
ANS: C
Many clients have unrealistic expectations of reconstructive surgery and envision an
appearance identical or equal in quality to the preburn state. The nurse should provide
accurate information that includes something to hope for. Pressure dressings prevent
further scarring; they cannot remove scars. The client and the family should be taught
the expected cosmetic outcomes.
DIF: Applying/Application REF: 488
KEY: Psychosocial response| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
5. A nurse assesses a client who has a burn injury. Which statement indicates the client
has a positive perspective of his or her appearance?
a. I will allow my spouse to change my dressings.
b. I want to have surgical reconstruction.
c. I will bathe and dress before breakfast.
d. I have secured the pressure dressings as ordered.
ANS: C
Indicators that the client with a burn injury has a positive perception of his or her
appearance include a willingness to touch the affected body part. Self-care activities
such as 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 dressing will
assist in decreasing complications but will not enhance self-perception.
DIF: Applying/Application REF: 488
KEY: Psychosocial response| coping
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Psychosocial Integrity
6. 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?
a. It is normal to feel some depression.
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Lomoarcpsd|26582732
Chapter 26 exam 3 Burns Shock
test bank
Nur Med Surg (Galen College of Nursing)
Chapter 26
1. 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?
a. Administer the prescribed tetanus toxoid vaccine.
b. Assess the clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients room.
ANS: D
Infection can occur when microorganisms from another person or from the
environment are transferred to the client. Although all of the interventions listed can
help reduce the risk for infection, handwashing is the most effective technique for
preventing infection transmission.
DIF: Applying/Application REF: 466
KEY: Infection control| Standard Precautions| collaboration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
Downloaded by NELSON KIIRU ()
,lOMoARcPSD|26582732
2. The nurse is caring for a client with an acute burn injury. Which action should the
nurse take to prevent infection by autocontamination?
a. Use a disposable blood pressure cuff to avoid sharing with other clients
b. Change gloves between wound care on different parts of the clients bo
c. Use the closed method of burn wound management for all wound care
d. Advocate for proper and consistent handwashing by all members of th
ANS: B
Autocontamination is the transfer of microorganisms from one area to another area
of the same clients body, causing infection of a previously uninfected area.
Although all techniques listed can help reduce the risk for infection, only changing
gloves between performing wound care on different parts of the clients body can
prevent autocontamination. DIF: Applying/Application REF: 485
KEY: Infection control| Standard Precautions
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment:
Safety and Infection Control
3. The nurse teaches burn prevention to a community group. Which statement by a
member of the group should cause the nurse the greatest concern?
a. I get my chimney swept every other year.
b. My hot water heater is set at 120 degrees.
c. Sometimes I wake up at night and smoke.
d. I use a space heater when it gets below zero.
ANS: C
House fires are a common occurrence and often lead to serious injury or death. The
nurse should be most concerned about a person who wakes up at night and smokes.
The nurse needs to question this person about whether he or she gets out of bed to
do so, or if this person stays in bed, which could lead to falling back asleep with a
lighted cigarette. Although it is recommended to have chimneys swept every year,
skipping a year does not pose as much danger as smoking in bed, particularly if the
person does not burn wood frequently. Water heaters should be set below 140 F.
Space heaters should be used with caution, and the nurse may want to ensure that
the person does not allow it to get near clothing or bedding.
DIF: Applying/Application REF: 472
KEY: Safety| smoking cessation MSC: Integrated Process:
Teaching/Learning
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
NOT: Client Needs Category: Health Promotion and Maintenance 4. A nurse cares
for a client who has facial burns. The client asks, Will I ever look the same? How
should the nurse respond?
a. With reconstructive surgery, you can look the same.
b. We can remove the scars with the use of a pressure dressing.
c. You will not look exactly the same but cosmetic surgery will help.
d. You shouldnt start worrying about your appearance right now.
ANS: C
Many clients have unrealistic expectations of reconstructive surgery and envision an
appearance identical or equal in quality to the preburn state. The nurse should provide
accurate information that includes something to hope for. Pressure dressings prevent
further scarring; they cannot remove scars. The client and the family should be taught
the expected cosmetic outcomes.
DIF: Applying/Application REF: 488
KEY: Psychosocial response| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
5. A nurse assesses a client who has a burn injury. Which statement indicates the client
has a positive perspective of his or her appearance?
a. I will allow my spouse to change my dressings.
b. I want to have surgical reconstruction.
c. I will bathe and dress before breakfast.
d. I have secured the pressure dressings as ordered.
ANS: C
Indicators that the client with a burn injury has a positive perception of his or her
appearance include a willingness to touch the affected body part. Self-care activities
such as 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 dressing will
assist in decreasing complications but will not enhance self-perception.
DIF: Applying/Application REF: 488
KEY: Psychosocial response| coping
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Psychosocial Integrity
6. 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?
a. It is normal to feel some depression.
Downloaded by NELSON KIIRU ()
