NCLEX Secrets - Level of Cognitive Ability (Analysis 46-50)

NCLEX Secrets - Level of Cognitive Ability

46. The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the emergent phase of the burn injury?

a) decreased heart rate
b) increased urinary output
c) increased blood pressure
d) elevated hematocrit levels

47. The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate which of the following signs in the client?

a) coma
b) flushing
c) dizziness
d) tachycardia



48. The client arrives at the emergency room following a burn injury that occurred in the basement at home and an inhalation injury is suspected. Which of the following would the nurse anticipate to be prescribed for the client?

a) 100% oxygen via an aerosol mask
b) oxygen via nasal cannula at 15 L/min
c) oxygen  via nasal cannula at 10 L/min
d) 100% oxygen via a tight-fitting, nonbreather face mask


49. The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which of the following would provide the most reliable indicator for determining the adequacy?

a) vital signs
b) urine output
c) mental status
d) peripheral pulses

50. The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique?

a) using sterile sheets and linens
b) performing strict hand washing technique
c) wearing gloves and gown only when giving direct care to the client
d) wearing protective garb, including a mask, gloves, cap, shoe covers, a gown, and plastic apron




NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE

46) D

- The emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

47) B

- Carbon monoxide levels between 11% to 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 61% result in death.

48) D

- If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Options A, B, and C are incorrect.

49) B

- Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. The most reliable indicator for determining adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.

50) C

- Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used. Protective garb, including gloves, caps, masks, shoe covers, gowns, and plastic aprons need to be worn when in the client’s room and when directly caring for the client.




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