ATI Care of Patients with Burns, Questions and Answers with Explanations, 100% Correct, Download to Score A

Test Bank

MULTIPLE CHOICE

1. The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN?

ANS: D

Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

2. When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination?

ANS: B

Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

3. The nurse is teaching burn prevention to a community group. Which information shared by a member of the group causes the nurse the greatest concern?

ANS: C

House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding. But the most immediate concern is the person’s smoking upon waking up at night.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Lifestyle Choices)

MSC: Integrated Process: Teaching/Learning

4. The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan?

ANS: B

Everyone should use smoke detectors and carbon monoxide detectors in their home environment (just not in a garage). Recommendations are that each bedroom should have a separate smoke detector. Smoke detectors should also be placed in the hallway of each story, in the kitchen, in each stairwell, and by each entrance. Space heaters can be a cause of fire if clothing, bedding, and other flammable objects are nearby. An escape route is very important, but successfully escaping also depends on early recognition of a fire, which is assisted by smoke detectors.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 520

TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning

5. A client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide?

ANS: C

Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring. They cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)

MSC: Integrated Process: Teaching/Learning