A+ GRADE TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 11TH EDITION BYHARDING Questions & Answers satisfaction guaranteed success ( CHAPTERS 21-29) latest update 2024 Chapter 21: Burns Test Bank MULTIPLE CHOICE 1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document theburn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destructionANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless becauseof the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibiterythema, blanching, and pain. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn hasthe following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion. ANS: C The patients laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patients fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 3. A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard,but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patients respiratory rate. d. Reposition the patient in high-Fowlers position and reassess breath sounds. ANS: B The patients history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriatebecause immediate action should occur. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
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