ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 27 Questions
Question 1 of 5
The nurse is assessing a patient who spilled hot oil on the right leg and foot and notes that the skin is red, swollen, and covered with large blisters. The patient states that they are very painful. Which of the following bum descriptions should the nurse document?
Correct Answer: C
Rationale: The erythema, swelling, and blisters point to a deep partial-thickness burn. With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial-thickness burns, the area is red, but no blisters are present.
Question 2 of 5
The nurse is admitting a patient to the burn unit who has an approximate 25% total body surface area (TBSA) burn and the following initial laboratory results: Hct 56%, Hb 172 g.L., serum K+ 4.8 mmol.L., and serum Na+ 135 mmol.L. Which of the following actions should the nurse anticipate implementing?
Correct Answer: B
Rationale: The patient's laboratory data show hemconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase.
Question 3 of 5
The nurse is admitting a patient to the burn unit who has burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. Which of the following actions should the nurse implement first?
Correct Answer: B
Rationale: The patient's history and clinical manifestations suggest airway edema and the health care provider should immediately be notified so that intubation can rapidly be done. 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 inappropriate because immediate action should occur.
Question 4 of 5
The nurse is caring for a patient with severe burns who is receiving crystalloid fluid replacement IV. ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30000 ml. The initial rate of administration is 1875 ml/hour. Which of the following infusion rates is accurate after the first 8 hours?
Correct Answer: C
Rationale: Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours (25% per each 8 hour period, respectively). In this case, the patient should receive half of the initial rate, or 938 ml/hour.
Question 5 of 5
The nurse is caring for a patient who is in the emergent phase of burn care. Which of the following nursing actions will be most useful in determining whether the patient is receiving adequate fluid infusion?
Correct Answer: D
Rationale: When fluid intake is adequate, the urine output will be at least 0.5-1 ml/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.