Exam 3: NUR265/ NUR 265 (Latest 2023/ 2024 Update) Advanced Concepts of Medical-Surgical Nursing Exam | Questions and Verified Answers| 100% Correct| Grade A - Galen

Exam 3: NUR265/ NUR 265 (Latest 2023/

2024 Update) Advanced Concepts of

Medical-Surgical Nursing Exam | Questions

and Verified Answers| 100% Correct| Grade

A - Galen

Q: Which finding indicates to the nurse that a client with a burn injury has a positive perception

of his appearance?

Answer:

Performing his own morning care.

Indicators that the client with a burn injury has a positive perception of his appearance includes

the 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

Q: Which finding indicates to the nurse that the client understands the psychosocial impact of

his severe burn injury?

Answer:

It is normal to feel depressed.

Q: Which finding is characteristic during the emergent period after a deep full thickness burn

injury?

Answer:

Urine output of 10ml/hr

During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for

glomerular filtration. As a result, urine output is greatly decreaseD. Foul-smelling discharge does

not occur during the emergent phase and blood pressure is usually low. Pain does not occur with

deep full-thickness burns.

Q: Which is the priority nursing diagnosis during the first 24 hours for a client with chemical

burns to the legs and arms that are red in color, edematous, and without pain?

Answer:

Decreased tissue perfusion

During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is

circumferential on an extremity, the swelling can compress blood vessels to such an extent that

circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating

the intervention of an escharotomy. Chemical burns do not cause inhalation injury and a

disrupted breathing pattern. Disturbed body image and disuse syndrome can develop. However,

these are not priority diagnoses at this time.

Q: Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report

to the physician immediately?

Answer:

Serum potassium,7.5 mmol/L (mEq/L)

Q: Which nursing intervention is likely to be most helpful in providing adequate nutrition while

the client is recovering from a thermal burn injury?

Answer:

Allowing the client to eat whenever he or she wants

Clients should request food whenever they think that they can eat, not just according to the

hospital's standard meal schedule. The nurse needs to work with a nutritionist to provide a highcalorie, high-protein diet to help with wound healing. Clients who can eat solid foods should

ingest as many calories as possible. Parenteral nutrition may be given as a last resort because it is

invasive and can lead to infectious and metabolic complications.

Q: hich statement best exemplifies the client's understanding of rehabilitation after a fullthickness burn injury?

Answer:

"My goal is to achieve the highest level of functioning that I can"

Q: Which statement indicates that a client with facial burns understands the need to wear a

facial pressure garment?

Answer:

"My facial scars will be less with the use of this facial mask"

Q: he client with a dressing covering the neck is experiencing some respiratory difficulty. What

is the nurse's best first action

Answer:

Loosen the dressing

Q: During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn

before dressing the wound. The client has all the following manifestations. Which manifestation

indicates that the client is having an adverse reaction to this topical agent?

Answer:

Increased serum creatinine levels.

Q: The burned client relates the following history of previous health problems. Which one

should alert the nurse to the need for alteration of the fluid resuscitation plan?

Answer:

MI 1 year ago