ADULT HEALTH 1 CJE EXAM WITH
ALL CORRECT ANSWERS
1. A nurse cares for a client with burn injuries during the resuscitation phase.
Which actions are priorities
during this phase? (Select all that apply.)
a. Administer analgesics.
b. Prevent wound infections.
c. Provide fluid replacement.
d. Decrease core temperature.
e. Initiate physical therapy.
ANS: A, B, C
Nursing priorities during the resuscitation phase include securing the airway,
supporting circulation and organ
perfusion by fluid replacement, keeping the client comfortable with
analgesics, preventing infection through
careful wound care, maintaining body temperature, and providing emotional
support. Physical therapy is
inappropriate during the resuscitation phase but may be initiated after the
client has been stabilized.
DIF: Applying/Application REF: 489
KEY: Skin lesions/wounds| pharmacologic pain management| infection control
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
,2. A nurse cares for a client with burn injuries who is experiencing anxiety
and pain. Which nonpharmacologic
comfort measures should the nurse implement? (Select all that apply.)
a. Music as a distraction
b. Tactile stimulation
c. Massage to injury sites
d. Cold compresses
e. Increasing client control
ANS: A, B, E
Nonpharmacologic comfort measures for clients with burn injuries include
music therapy, tactile stimulation,
massaging unburned areas, warm compresses, and increasing client control.
DIF: Remembering/Knowledge REF: 496
KEY: Nonpharmacologic pain management
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nurse plans care for a client with burn injuries. Which interventions
should the nurse include in this clients
plan of care to ensure adequate nutrition? (Select all that apply.)
a. Provide at least 5000 kcal/day.
b. Start an oral diet on the first day.
c. Administer a diet high in protein.
d. Collaborate with a registered dietitian.
e. Offer frequent high-calorie snacks.
ANS: A, C, D, E
,A client with a burn injury needs a high-calorie diet, including at least 5000
kcal/day and frequent high-calorie
snacks. The nurse should collaborate with a registered dietitian to ensure the
client receives a high-calorie and
high-protein diet required for wound healing. Oral diet therapy should be
delayed until GI motility resumes.
DIF: Remembering/Knowledge REF: 501
KEY: Nutrition| nutritional requirements
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. A nurse cares for an older client with burn injuries. Which age-related
changes are paired appropriately with
their complications from the burn injuries? (Select all that apply.)
a. Slower healing time Increased risk for loss of function from contracture
formation
b. Reduced inflammatory response Deep partial-thickness wound with
minimal exposure
c. Reduced thoracic compliance Increased risk for atelectasis
d. High incidence of cardiac impairments Increased risk for acute kidney
injury
e. Thinner skin May not exhibit a fever when infection is present
ANS: A, C, D
Slower healing time will place the older adult client at risk for loss of function
from contracture formation due
to the length of time needed for the client to heal. A pre-existing cardiac
impairment increases risk for acute
kidney injury from decreased renal blood flow, and reduced thoracic
compliance places the client at risk for
, atelectasis. Reduced inflammatory response places the client at risk for
infection without a normal response,
including fever. Clients with thinned skin are at greater risk for deeper
wounds from minimal exposure.
DIF: Remembering/Knowledge REF: 490 KEY: Older adult
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Health Promotion and Maintenance
5. A nurse plans care for a client with burn injuries. Which interventions
should the nurse implement to prevent
infection in the client? (Select all that apply.)
a. Ask all family members and visitors to perform hand hygiene before
touching the client.
b. Carefully monitor burn wounds when providing each dressing change.
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care 9e 210
c. Clean equipment with alcohol between uses with each client on the unit.
d. Allow family members to only bring the client plants from the hospitals gift
shop.
e. Use aseptic technique and wear gloves when performing wound care.
ANS: A, B, E
To prevent infection in a client with burn injuries the nurse should ensure
everyone performs hand hygiene,
monitor wounds for signs of infection, and use aseptic technique, including
wearing gloves when performing
wound care. The client should have disposable equipment that is not shared
with another client, and plants
should not be allowed in the clients room.
DIF: Applying/Application REF: 499
ALL CORRECT ANSWERS
1. A nurse cares for a client with burn injuries during the resuscitation phase.
Which actions are priorities
during this phase? (Select all that apply.)
a. Administer analgesics.
b. Prevent wound infections.
c. Provide fluid replacement.
d. Decrease core temperature.
e. Initiate physical therapy.
ANS: A, B, C
Nursing priorities during the resuscitation phase include securing the airway,
supporting circulation and organ
perfusion by fluid replacement, keeping the client comfortable with
analgesics, preventing infection through
careful wound care, maintaining body temperature, and providing emotional
support. Physical therapy is
inappropriate during the resuscitation phase but may be initiated after the
client has been stabilized.
DIF: Applying/Application REF: 489
KEY: Skin lesions/wounds| pharmacologic pain management| infection control
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
,2. A nurse cares for a client with burn injuries who is experiencing anxiety
and pain. Which nonpharmacologic
comfort measures should the nurse implement? (Select all that apply.)
a. Music as a distraction
b. Tactile stimulation
c. Massage to injury sites
d. Cold compresses
e. Increasing client control
ANS: A, B, E
Nonpharmacologic comfort measures for clients with burn injuries include
music therapy, tactile stimulation,
massaging unburned areas, warm compresses, and increasing client control.
DIF: Remembering/Knowledge REF: 496
KEY: Nonpharmacologic pain management
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nurse plans care for a client with burn injuries. Which interventions
should the nurse include in this clients
plan of care to ensure adequate nutrition? (Select all that apply.)
a. Provide at least 5000 kcal/day.
b. Start an oral diet on the first day.
c. Administer a diet high in protein.
d. Collaborate with a registered dietitian.
e. Offer frequent high-calorie snacks.
ANS: A, C, D, E
,A client with a burn injury needs a high-calorie diet, including at least 5000
kcal/day and frequent high-calorie
snacks. The nurse should collaborate with a registered dietitian to ensure the
client receives a high-calorie and
high-protein diet required for wound healing. Oral diet therapy should be
delayed until GI motility resumes.
DIF: Remembering/Knowledge REF: 501
KEY: Nutrition| nutritional requirements
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. A nurse cares for an older client with burn injuries. Which age-related
changes are paired appropriately with
their complications from the burn injuries? (Select all that apply.)
a. Slower healing time Increased risk for loss of function from contracture
formation
b. Reduced inflammatory response Deep partial-thickness wound with
minimal exposure
c. Reduced thoracic compliance Increased risk for atelectasis
d. High incidence of cardiac impairments Increased risk for acute kidney
injury
e. Thinner skin May not exhibit a fever when infection is present
ANS: A, C, D
Slower healing time will place the older adult client at risk for loss of function
from contracture formation due
to the length of time needed for the client to heal. A pre-existing cardiac
impairment increases risk for acute
kidney injury from decreased renal blood flow, and reduced thoracic
compliance places the client at risk for
, atelectasis. Reduced inflammatory response places the client at risk for
infection without a normal response,
including fever. Clients with thinned skin are at greater risk for deeper
wounds from minimal exposure.
DIF: Remembering/Knowledge REF: 490 KEY: Older adult
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Health Promotion and Maintenance
5. A nurse plans care for a client with burn injuries. Which interventions
should the nurse implement to prevent
infection in the client? (Select all that apply.)
a. Ask all family members and visitors to perform hand hygiene before
touching the client.
b. Carefully monitor burn wounds when providing each dressing change.
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care 9e 210
c. Clean equipment with alcohol between uses with each client on the unit.
d. Allow family members to only bring the client plants from the hospitals gift
shop.
e. Use aseptic technique and wear gloves when performing wound care.
ANS: A, B, E
To prevent infection in a client with burn injuries the nurse should ensure
everyone performs hand hygiene,
monitor wounds for signs of infection, and use aseptic technique, including
wearing gloves when performing
wound care. The client should have disposable equipment that is not shared
with another client, and plants
should not be allowed in the clients room.
DIF: Applying/Application REF: 499
