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The nursing student is caring for the client with open wound burns. Which priority nursing interventions does the nursing student include for this client? (Select all that apply.)
A) Provides cushions and rugs for comfort
B) Cleans equipment daily
C) Performs frequent handwashing
D) Provides fresh fruits and vegetables
E) Performs gloved dressing changes
F) Provides plants and flowers in the room
G) Uses disposable dishes
B) Rationale: Daily cleaning of the equipment and general housekeeping are essential for infection control.
C) Rationale: All isolation methods use proper and consistent handwashing as the most effective technique for preventing infection transmission.
E) Rationale: Use of asepsis requires all health care personnel to wear gloves during all contact with open wounds.
G) Rationale: Disposable items (e.g., pillows, syringes, and dishes) are used as much as possible.
What is the best method to prevent autocontamination for the client with burns?
A) Change gloves when handling wounds on different areas of the body.
B) Ensure that the client is in isolation therapy.
C) Restrict visitors.
D) Watch for early signs of infection.
Gloves should be changed when handling wounds on different areas of the body and between handling old and new dressings.
Which strategies does the nurse include when teaching the college student about fire prevention in their dormitory room?
A) use of space heaters.
B) Check water temperature before a bath or shower.
C) Do not smoke in bed.
D) Wear sunscreen.
Smoking in bed increases the risk for fire because the person could fall asleep
When teaching fire safety to parents at a school function, the school nurse offers advice about the placement of smoke and carbon monoxide detectors with which statement?
A) ''Every bedroom should have a separate smoke detector.''
B) ''Every room in the house should have a smoke detector.''
C) ''If you have a smoke detector, you don't need a carbon monoxide detector.''
D) ''The kitchen and bedrooms are the only rooms that need smoke detectors.''
The number of detectors needed depends on the size of the home. Recommendations are that each bedroom should have a separate smoke detector, at least one detector should be placed in the hallway of each floor of the house, and at least one detector is needed for the kitchen, stairway, and home entrance.
The nurse is caring for the client with burns to the face. Which statement by the client requires further evaluation by the nurse?
A) ''I am getting used to looking at myself.''
B) ''I don't know what I will do when people stare at me.''
C) ''I know that I will never look like I used to, even after the scars heal.''
D) ''My spouse does not stare at the scars as much as in the beginning.''
This statement indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques.
The client with burn injuries states, ''I feel so helpless.'' Which nursing intervention is most helpful for this client?
A) Encourages participation in wound care
B) Encourages visitors
C) Tells the client that he or she will be fine
D) Tells the client that his or her feelings are normal
Encouraging participation in wound care will offer the client some sense of control.
The nurse is caring for the client with burns. Which question does the nurse ask the client and family to assess their coping strategies?
A) ''Do you support each other?''
B) ''How do you plan to manage this situation?''
C) ''How have you handled similar situations before?''
D) ''Would you like a counselor?''
This question assesses whether the client's and the family's coping strategies may be effective.
The client who was the sole survivor in a house fire says, ''I feel so guilty. Why did I survive?'' What is the best response by the nurse?
A) ''Do you want to pray about it?''
B) ''I know, and you will have to learn to adapt to a new body image.''
C) ''Tell me more.''
D) ''There must be a reason.''
This response encourages therapeutic grieving.
Several clients have been brought to the ED after an office building fire. Which client is at greatest risk for inhalation injury?
A) Woman who is frantically explaining what happened to the nurse
B) Man who suffered burn injuries in a closed space
C) Woman with burns to the extremities
D) Man with thick, tan-colored sputum
The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke.
The newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations?
A) Painful red and white blisters
B) Painless, brownish-yellow eschar
C) Painful reddened blisters
D) Painless black skin with eschar
Painful red and white blisters accompany a deep partial-thickness burn
The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first?
A) Administers a diuretic
B) Provides a fluid bolus
C) Recalculates fluid replacement based on time of hospital arrival
D) Titrates fluid replacement
The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids).
The client is being admitted with burn injuries. Which priority does the nurse anticipate within the first 24 hours?
A) Body temperature assessment
B) Emotional support
C) Fluid resuscitation
D) Urine output monitoring
The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury.
The nurse is evaluating the effectiveness of fluid resuscitation for the client in the emergent phase of burn injury. Which finding does the nurse correlate with clinical improvement?
A) Blood urea nitrogen (BUN), 36 mg/dL
B) Creatinine, 2.8 mg/dL
C) Urine output, 40 mL/hr
D) Urine specific gravity, 1.042
Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL or 0.5 mL/kg/hr.
Which assessment does the nurse prioritize for the client in the acute phase of burn injury?
A) Bowel sounds
B) Muscle strength
C) Signs of infection
D) Urine output
The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery.
The client is in the acute phase of burn injury. In which situation does the nurse decide to coordinate with the nutritionist?
A) To discourage having food brought in from the client's favorite restaurant
B) To provide more palatable choices for the client
C) To help the client lose weight
D) To plan additions to the standard nutritional pattern
Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance.
Which clinical manifestation is indicative of wound healing for the client in the acute phase of burn injury?
A) Pale, boggy, dry, or crusted granulation tissue
B) Increasing wound drainage
C) Scar tissue formation
D) Sloughing of grafts
Indicators of wound healing include the presence of granulation, re-epithelization, and scar tissue formation.
The client is in the emergent phase of burn injury. Which route does the nurse use to administer pain medication to the client?
During the resuscitation postburn phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.
Which factors indicate that the client's burn wounds are becoming infected? (Select all that apply.)
A) Dry, crusty granulation tissue
B) Elevated blood pressure
D) Increasing wound drainage
E) Swelling of the skin around wound
A: Pale, boggy, dry, or crusted granulation tissue is a sign of infection.
D: Swelling or edema of the skin around the wound is a sign of infection.
E: Tachycardia is a systemic sign of infection.
To position the client's burned upper extremities appropriately, how does the nurse position the client's elbow?
A) In a neutral position
B) In a position of comfort
C) Slightly flexed
D) Slightly hyperextended
The neutral position is the correct placement of the elbow to prevent contracture development.
In assessing the client in the rehabilitative phase of burn therapy, which nursing diagnosis does the nurse anticipate?
A) Acute Pain
B) Excess Fluid Volume
C) Disturbed Body Image
D) Risk for Infection
In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected.
A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member?
A) "The last tetanus injection was less than 5 years ago."
B) "Burn wound conditions promote the growth of Clostridium tetani."
C) "The wood in the fire had many nails, which penetrated the skin."
D) "The injection was prescribed to prevent infection from Pseudomonas."
Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid, 0.5 mL given IM, enhances acquired immunity to C. tetani. This agent is routinely given when the client is admitted to the hospital.
The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials?
A) Reduction of bacterial growth in the wound and prevention of systemic sepsis
B) Prevention of cross-contamination from other clients in the unit
C) Enhanced cell growth
D) Reduced need for a skin graft
Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds.
The nurse is caring for a burn client who is receiving topical gentamicin sulfate (Garamycin). What laboratory value will the nurse plan to monitor?
A) Blood glucose
B) C-reactive protein
C) Serum and urine creatinine
D) Platelet count
Topical gentamicin may have nephrotoxic effects, and the nurse should monitor serum and urine creatinine clearance before and during treatment.
When delegating care for clients on the burn unit, which client will the charge nurse assign to an RN who has floated to the burn unit from the pediatric unit?
A) Burn unit client who is being discharged after 6 weeks and needs teaching about wound care
B) Recently admitted client with a high-voltage electrical burn
C) A client who has a 25% total body surface area burn injury for whom daily wound debridement has been prescribed
D) Client receiving IV lactated Ringer's solution at 100mL/hr
An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath.
The nurse on a burn unit has just received change-of-shift report about these clients. Which client will the nurse assess first?
A) Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain
B) Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!"
C) An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans
D) Older adult client admitted yesterday with partial and full thickness burns over 40% of the body who is receiving IV fluids at 250mL/Hr
Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The client with difficulty breathing needs immediate assessment and intervention
A client with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which physician request first?
A) Give oxygen per non-rebreather mask at 100% FiO2
B) Infuse lactated Ringer's solution at 150mL/hr
C) Give morphine sulfate 4 to 10mg IV for pain control
D) Insert a 14 Fr retention catheter
Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level.
Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area will be of greatest concern to the nurse?
A) Bowel sounds are absent
B) The pulse oximetry level is 91%
C) The serum potassium level is 8.1 mEq/L
D) Urine output since admission is 370mL
An elevated serum potassium level can cause cardiac arrest.
The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication?
A) Furosemide (Lasix)
B) Digoxin (Lanoxin)
C) Dopamine (Inotropin)
D) Morphine sulfate
Furosemide, a diuretic, generally is not given to improve urine output for burn clients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs.
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