NUR 2243 Exam 3 Professional Nursing Skills I – Rasmussen
Latest 2023 / 2024
- The registered nurse assigns a client who has an open burn wound to a
licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client?
a) Administer the prescribed tetanus toxoid vaccine.
b) Assess the clients’ wounds for signs of infection.
c) Encourage the client to breathe deeply every hour.
ANS: D
Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.
- The nurse is caring for a client with an acute burn injury. Which action
should the nurse take to prevent infection by anticontamination?
a) Use a disposable blood pressure cuff to avoid sharing with other clients.
c) Use the closed method of burn wound management for all wound care.
d) Advocate for proper and consistent handwashing by all members of the
staff.
ANS: B
Anticontamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the client’s body can prevent anticontamination. 1 / 4
- The nurse teaches burn prevention to a community group. Which statement
by a member of the group should cause the nurse the greatest concern?
a) I get my chimney swept every other year.
b) My hot water heater is set at 120 degrees.
d) I use a space heater when it gets below zero.
ANS: C
House fires are a common occurrence and often lead to serious injury or death.The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently.Water heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.
- A nurse assesses a client who has a burn injury. Which statement indicates
the client has a positive perspective of his or her appearance?
a) I will allow my spouse to change my dressings.
b) I want to have surgical reconstruction.
d) I have secured the pressure dressings as ordered.
ANS: C
Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance.Wearing the dressing will assist in decreasing complications but will not enhance self-perception. 2 / 4
- A nurse cares for a client who has facial burns. The client asks, Will I ever
look the same? How should the nurse respond?
a) With reconstructive surgery, you can look the same.
b) We can remove the scars with the use of a pressure dressing.
d) You shouldn’t start worrying about your appearance right now.
ANS: C
Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the pre-burn state. The nurse should provide accurate information that includes something to hope for.Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.
- A nurse receives new prescriptions for a client with severe burn injuries who
is receiving fluid resuscitation per the Parkland formula. The client’s urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?
a) Increase intravenous fluids by 100 mL/hr.
c) Continue to monitor urine output hourly.
d) Draw blood for serum electrolytes STAT.
ANS: B
The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr.Based on this client’s inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused. 3 / 4
- The nurse assesses a client who has a severe burn injury. Which statement
indicates the client understands the psychosocial impact of a severe burn injury?
b) I will go back to work immediately.
c) I will not feel anger about my situation.
d) Once I get home, things will be normal.
ANS: A
During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur.Clients need to know that problems of physical care and psychological stresses may be overwhelming.
- An emergency room nurse assesses a client who was rescued from a home
fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first?
b) Provide small quantities of ice chips and sips of water.
c) Request a prescription for an antitussive medication.
d) Ask the respiratory therapist to provide humidified air.
ANS: A
Brassy cough and wheezing are some of the signs seen with inhalation injury.The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.
- / 4