13976196-Nursing-care-for-Burns

13976196-Nursing-care-for-Burns - Interventions for Clients...

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Unformatted text preview: Interventions for Clients with Burns MULTIPLE CHOICE 1. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness ANS: A The characteristics of the wound meet the criteria for a full-thickness injury (color that is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm and inelastic). DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity; 2. The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness ANS: B The characteristics of the wound meet the criteria for a superficial partial- thickness injury (color that is pink or red; blisters; pain present and high). DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity; 3. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? A. The medication will be effective more quickly than if given intramuscularly. B. It is less likely to interfere with the client’s breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client delayed gastric emptying. ANS: C Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment; 4. Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D ANS: D Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in full- thickness burns....
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This note was uploaded on 05/16/2011 for the course NURSING 112 taught by Professor Brinley during the Spring '11 term at Pace.

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13976196-Nursing-care-for-Burns - Interventions for Clients...

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