Quiz 2(Burns

)

1. When assessing a patient who spilled hot oil on his right leg and foot. The nurse notes that the skin is red, swollen and covered in large blisters. What type of burn is this? Answer: Deep partial thickness 2. On admit to the burn unit, patient has 25% BSA, HCT 56%, Hgb 17.2, potassium 4.8, Sodium 135. What should the nurse do first? Answer: increase fluid rate (↑ Hct can increase risk for stroke) 3. During the emergent phase of burn care, which nursing action will be most useful in determining whether a patient is receiving adequate fluid infusion? Answer: measure hourly urine output 4. Patient has a deep-partial and full thickness to face and chest wound treatment and open method. What action should be included? Answer: wear gown, caps, mask, gloves during care 5. A patient with circumferential burns of both arms develops a decrease radial pulse pressure, strength and numbness in his fingers. Which action should the nurse take? Answer: notify health care provider 6. Which medication is needed for partial thickness wound before debridement is performed? Answer: Dilaudid 7. The nurse caring for a patient with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when? Answer: Large amounts of pale urine 8. What is priority assessment for a patient with a history of an electrical burn? Answer: extremity movement 9. After an employee spills industrial acid on arms and legs at work, what is the priority action that the occupational health care nurse should take? Answer: flush with large amounts of H2O

During the primary assessment of the patient the nurse should? Answer: obtain Glascow Coma Scale 15. A patient is unconscious after a fall from a ladder is transported to the emergency department by a family member. Which action should the nurse take next? Answer: observe the patients respiratory effort 14. Six hours after a thermal burn covering 50% of the patients total body surface area (TBSA) the nurse obtains data when assessing the patient. The emergency department triage nurse is assessing four victims of an automobile accident. When planning for a response to the potent use of small pox as an agent of terrorism the emergency department will plan to obtain? Answer: Vaccine 18. which patient has highest priority? .Quiz 2(Burns) 10. What priority information should the nurse communicate? Answer: Urine output is 20 ml per HR for past 2 hours 12. What is first priority? Answer: 100% o2 with non-re-breather mask 13. During the first survey patient has multiple injuries. What should the nurse do next? Answer: Fluid= 2 large bore IV’s (to prevent shock) 16. the nurse will plan to? Answer: attach a cardiac monitor 17. Which action should the RN take first for a patient with a facial and chest burn from a house fire? Answer: Auscultate lung sounds 11. During a primary assessment of a trauma victim the nurse determines that the patient is breathing and has an unobstructed airway. RN notes bright red skin in patient and found with smoke inhalation. When preparing to rewarm a patient with hypothermia. absent pedal pulse and swollen leg.

what action is most important? Answer: Assess LOC . Patient comes into the ED after ingesting 20-30 Tylenol. A patient has a near drowning and awakes breathing. A patient with a head injury whose vital signs are BP 128/68. Trauma nursing= Red Tags get triaged and treated first!! 27. Pulse 55. Following a head injury an unconscious 32 year-old patient is admitted to the emergency department. Which action is best? watch Answer: Give the family a choice if they want to stay in the room and 21. Which action should the nurse take? Answer: Check for glucose 25.Quiz 2(Burns) Answer: Sucking chest wound 19. pulse 110. Order ICP is 21. A patient’s family members are in a patient’s room and the patient cardiac arrests. The spouse and children stay at the patient’s bedside? Answer: stay and explain every treatment or procedure 24. After noting that a patient with a head injury has clear nasal drainage. RR 12 (Cushing Triad) 22. The emergency department personal starts resuscitation measures. which action will the nurse plan to take? Answer: Prepare for immediate craniotomy 26. resp 10. What action is most important? Answer: Auscultate breath sounds 20. what action is best? Answer: Give N-actylcysteine (Mucomyst) 23. A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which vital changes are of most concern? Answer: BP 156/60.

Applies painful stimuli to nail bed. internal rotation. A patient suspected with bacterial meningitis and a lumbar puncture? Answer: Give Rocephin (medication) 29. and adduction? Answer: decorticate 30.Quiz 2(Burns) 28. unconscious patient. what is the intervention? Answer: Keep head of bed above 30 degrees . An unconscious patient with nursing diagnosis of ineffective perfusion related to swelling.

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.