Question 5291)
A severely burned man had his last tetanus shot when he started work at his job
two years ago. What should the nurse expect to administer now?
A. Tetanus toxoid booster
B. Tetanus antitoxin
C. Hyperimmune human tetanus globulin
D. DPT booster
Answer: A
Explanation: Tetanus toxoid given to when the client has had prior tetanus inoculations. Hyperimmune tetanus
globulin is given when the person has not had prior tetanus immunization. DTP is not given past the age of 6 years.
Tetanus antitoxin is given when a person has not been immunized and considerable time has elapsed from the time
of the injury. Tetanus antitoxin helps to fight a tetanus infection that is developing. Tetanus toxoid and immune
globulin help to prevent tetanus infection from developing.
Question 5292)
A severely burned client is to be admitted from the emergency department. What
type of room should the nurse prepare for the client?
A. A semi-private room with a noninfectious client
B. A room with a postoperative client
C. An isolation room
D. A private room with a private bath
Answer: C
Explanation: Burn victims should be placed in isolation because they are very susceptible to infection
Question 5293)
The nurse is planning care for a newly burned client. What is the priority nursing
observation to be made during the first 48 hours after the burn?
A. Hourly blood pressure
B. Assessment of skin color and capillary refill
C. Hourly urine measurement
D. Frequent assessment for pain
Answer: C
Explanation: Fluid replacement is based on hourly measurement of urine output. The other observations are
important and should be done, but they are not the highest priority
Question 5294)
Cimetidine (Tagamet) is ordered IV every six hours for a person with severe burns.
What is the primary reason for administering Tagamet to this client?
A. To prevent infection
B. To restore electrolyte balance
C. To promote renal function
D. To prevent Curling’s ulcers
Answer: D
Explanation: Curling’s (stress) ulcers occur frequently in burn victims. Tagamet is a histamine blocker that reduces
gastric acid and helps to prevent the development of ulcers.
Question 5295)
A client who was severely burned goes to the Hubbard tank daily. Tanking sessions
are limited to a half hour for which reason?
A. A longer period of time is too tiring
B. Eschar becomes difficult to remove with longer soaking.
C. Prolonged soaking causes electrolyte dilution.
D. The water becomes too cool and may cause chilling.
Answer: C
Explanation: The water in the Hubbard tank is hypotonic, and sodium loss occurs through the open wounds. The
bath may be painful and fatiguing for the client. The primary reason is the physiological problem of sodium loss.
Question 5296)
Silver nitrate dressings are applied to burns on an adult. What should be included
in the nursing care plan?
A. Change the dressings every two hours
B. Keep the dressings wet.
C. Carefully monitor fluid intake
D. Observe for black discoloration
Answer: B
Explanation: Silver nitrate dressings must always be kept wet, or the silver nitrate is not effective. Silver nitrate
does cause black discoloration, but this is incidental and not a major nursing consideration.
Question 5297)
The nurse is caring for a client who is having silver nitrate dressings. Which lab
values should the nurse monitor?
A. Blood urea nitrogen (BUN)
B. Blood gases
C. Complete blood count (CBC)
D. Serum electrolytes
Answer: D
Explanation: Silver nitrate can cause depletion of potassium, sodium, and chloride; therefore, serum electrolytes
are essential.
Question 5298)
A young man has extensive burns on the front and back of the chest. His
treatment includes the use of Sulfamylon to the burned areas. How should the nurse apply this
medication?
A. With a sterile, gloved hand
B. With a sterile applicator
C. With sterile 4 × 4’s
D. By aerosol spray
Answer: A
Explanation: A sterile, gloved hand is the preferred way to apply topical antimicrobials.
Question 5299)
An electrician was wearing a glove that had a hole in it when he grabbed a “hot”
wire. His coworkers came to him immediately and called the rescue squad. When the industrial
nurse reached him, the electric current had been shut off. What action should the nurse take
initially?
A. Dress the entrance and exit wounds
B. Check respirations and pulse rate
C. Remove clothing from the burned area
D. Roll him in a blanket
Answer: B
Explanation: Electric burns cause cardiac arrhythmias. Checking respirations and the pulse rate is the highest
priority. There is no need to remove clothing or roll a victim of an electric burn in a blanket because there are no
flames. Dressing wounds is of lesser priority than assessing cardiac and respiratory functioning.
Question 5300)
A client who has just been diagnosed with psoriasis asks the nurse what should be
done to prevent family members from getting the condition. What should the nurse include when
responding to this question?
A. Showering daily with antiseptic soap should be sufficient.
B. Wearing clothing over the affected part and washing clothes separately from the rest of the family are all that is
necessary
C. Psoriasis is not contagious, so no special precautions are necessary.
D. Psoriasis is transmitted primarily by direct contact with the skin.
Answer: C
Explanation: Psoriasis is not contagious
No comments:
Post a Comment