The nursing care plan of a patient who is in the acute/immediate phase of burn care identifies a ...

The nursing care plan of a patient who is in the acute/immediate phase of burn care identifies a nursing diagnosis of Risk for Infection due to burns. What intervention should be prioritized in response to this diagnosis?
 
  A) Intravenous administration of broad-spectrum, prophylactic antibiotics
  B) Vigilant application of infection-control precautions such as gloves, gowns, and masks
  C) Administration of oral prophylactic antibiotics
  D) Regular disinfecting of the patient's intact skin and the immediate bedside environment

Question 2

The nurse's hourly assessment of a male patient with burns reveals that the patient's blood pressure is trending downward and that his heart rate is trending upward. What intervention has the potential to resolve these trends?
 
  A) Increasing the rate of the patient's fluid resuscitation
  B) Performing intermittent urinary catheterization
  C) Increasing the rate of the patient's morphine infusion
  D) Repositioning the patient

Question 3

The emergency department (ED) team is conducting immediate care of a patient admitted with burns estimated at 40 total body surface area.
 
  The nurse in the ED and the other members of the team are aware of the need to customize the rate of fluid resuscitation and will base this rate on what data?
  A) Level of consciousness and pain levels
  B) Abdominal girth measurements and abdominal tone
  C) Vital signs and urine output
  D) Arterial blood gases and breath sounds

Question 4

A 44-year-old man has suffered severe electrical burns while working on an infrastructure project. Rapid assessment at the scene of the accident reveals that he has burns to his entire lower body and is currently unconscious.
 
  What is the priority action in the immediate care of this patient?
  A) Cooling the patient's burns
  B) Establishing intravenous access
  C) Covering the patient's burns with sterile gauze
  D) Maintaining a patent airway

Question 5

A teenage boy has been brought by ambulance to the emergency department from a house fire in which he has suffered extensive injuries. In addition to burns, early blood tests reveal carbon monoxide poisoning.
 
  This assessment finding will be treated by what intervention?
  A) Administration of 100 oxygen
  B) Intubation and administration of bronchodilators
  C) Deep suctioning
  D) Incentive spirometry

Question 6

The nurse is reviewing the admission blood work of a patient who is being treated for significant burns. The patient's serum potassium level is 7.1 mEq/L (normal 3.5 to 5.0 mEq/L), which is primarily a result of:
 
  A) Acute renal failure
  B) Massive adrenal release of glucocorticoids
  C) Myocardial stress
  D) Cell destruction

Question 7

The nurse is documenting an hourly assessment of a patient who is being treated for full-thickness burns to his lower extremities. Assessment has revealed that the patient's abdominal girth is steadily increasing.
 
  This is most likely attributable to what pathophysiological process?
  A) Presence of free air under the patient's diaphragm
  B) Third spacing
  C) Bladder distention due to urinary retention
  D) Paralytic ileus