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

Quiz 2(Burns)

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

Quiz 2(Burns)

Answer: Sucking chest wound 19. A patient has a near drowning and awakes breathing. What action is most important? Answer: Auscultate breath sounds 20. A patients family members are in a patients room and the patient cardiac arrests. The emergency department personal starts resuscitation measures. Which action is best? watch Answer: Give the family a choice if they want to stay in the room and

21. A patient with a head injury whose vital signs are BP 128/68, pulse 110, resp 10. Which vital changes are of most concern? Answer: BP 156/60, Pulse 55, RR 12 (Cushing Triad) 22. Patient comes into the ED after ingesting 20-30 Tylenol, what action is best? Answer: Give N-actylcysteine (Mucomyst) 23. Following a head injury an unconscious 32 year-old patient is admitted to the emergency department. The spouse and children stay at the patients bedside? Answer: stay and explain every treatment or procedure 24. After noting that a patient with a head injury has clear nasal drainage. Which action should the nurse take? Answer: Check for glucose 25. A patient who is suspected of having an epidural hematoma is admitted to the emergency department, which action will the nurse plan to take? Answer: Prepare for immediate craniotomy 26. Trauma nursing= Red Tags get triaged and treated first!! 27. Order ICP is 21, what action is most important? Answer: Assess LOC

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