Nokea
The nurse is conducting a staff in-service on managing an acute burn. The nurse should reinforce the utilization of which formula to guide fluid resuscitation?
- A. 4 mL x kg x Total Body Surface Area (TBSA) burned
- B. 30 mL/kg
- C. 0.5 mL/kg/hr
- D. 0.10 mL/kg/hr
Correct Answer: A
Rationale: The Parkland formula (4 mL x kg x TBSA burned) is used to calculate fluid resuscitation needs in burn patients to restore circulating volume.
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The nurse works with elderly clients. The nurse should recognize which of the following are physical changes associated with the aging client? Select all that apply.
- A. Pronounced wrinkles on the face
- B. Decreased size of the nose and ears
- C. Increased growth of facial hair
- D. Neck wrinkles
- E. Increased height
Correct Answer: A, C, D
Rationale: Aging causes pronounced wrinkles on the face and neck and increased facial hair due to hormonal changes. Nose and ears enlarge, and height decreases due to spinal compression.
The nurse documents the presence of a skin lesion as a 'palpable solid mass measured at 1 cm.' What types of skin lesions might this describe? Select all that apply.
- A. Macule
- B. Patch
- C. Plaque
- D. Nodule
- E. Bulla
- F. Pustule
Correct Answer: C, D
Rationale: A palpable solid mass of 1 cm could be a plaque (elevated, >1 cm) or nodule (solid, deeper, 0.5-2 cm). Macules and patches are flat, bullae are fluid-filled, and pustules contain pus.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 2 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Based on the client's injuries, the client has sustained a ..........total body surface area burn.
- A. 18%
- B. 27%
- C. 36%
Correct Answer: C
Rationale: Using the rule of nines: right arm (9%), right hand (1%), right torso (9%), back (18%) = 9 + 1 + 9 + 18 = 37% (closest to 36% in options).
Which of the following would the nurse recognize as an accurate statement regarding pressure ulcers? Select all that apply.
- A. In a stage Il pressure ulcer, part of the dermis and epidermis are lost.'
- B. In a stage I pressure ulcer, there is a loss of integrity of the epidermis only.'
- C. In a stage Ill pressure ulcer, a deep tissue injury can expose fat.'
- D. In a stage IV pressure ulcer, the base of the wound is covered by eschar.'
- E. Stage Ill involves extensive tissue damage and can lead to bone and muscle involvement.'
Correct Answer: A, C
Rationale: Stage II involves partial loss of dermis and epidermis, and Stage III can expose fat. Stage I is non-blanchable redness, Stage IV may expose bone/muscle, and eschar is not always present.
A nurse is caring for a client at risk of developing pressure ulcers. Which of the following is an intrinsic risk factor that contributes to this increased risk?
- A. Shearing
- B. Friction
- C. Impaired tissue perfusion
- D. Pressure
Correct Answer: C
Rationale: Impaired tissue perfusion is an intrinsic risk factor because it originates within the body, affecting blood flow and tissue oxygenation, which can lead to pressure ulcer development. Shearing, friction, and pressure are extrinsic factors as they are external forces acting on the skin.