ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 27 Questions
Question 1 of 5
The nurse is caring for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury. Which of the following interventions should the nurse include in the plan of care to maintain adequate nutrition?
Correct Answer: A
Rationale: Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24-48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.
Question 2 of 5
Which of the following snacks will be best for the nurse to offer to a patient with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn treatment?
Correct Answer: D
Rationale: A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.
Question 3 of 5
The staff nurse is supervising a student nurse on the burn unit. Which of the following actions by the student nurse require that the staff nurse intervene?
Correct Answer: A
Rationale: Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.
Question 4 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 5 of 5
The nurse is caring for a patient who has partial-thickness burns. Which of the following prescribed medications will be best for the nurse to use before wound debridement?
Correct Answer: D
Rationale: Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effect of opioids.