Care of Patients with Burns
a nurse plans care for a client with burn injuries. which interventions should the nurse include in this clients plan of care to ensure adequate nutrition?
-provide at least 5000kcal/day -admin a diet high in protein -collaborate w/ a registered dietitian -offer frequent high-calorie snacks
a nurse cares for a client with burn injuries during the resuscitation phase. which actions are priorities during this phase?
-administrier analgesics -prevent wound infections -provide fluid replacement
a nurse plans care for a client with burn injuries. which interventions should the nurse implement to prevent infection in this client?
-ask all family members and visitors to perform hand hygiene before touching the client. -carefully monitor burn wounds when providing each dressing change. -use aseptic technique and wear gloves when performing wound care.
a nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
urine output of 20 ml/hr
The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide the LPN when assigning this client?
wash your hands on entering the clients room.
a nurse cares for a client who has burn injuries. the clients wife asks, when will his high risk for infection decrease? how should the nurse respond?
when all of his burn wounds have closed.
A nurse cares for a client who has facial burns. the client asks, will I ever look the same? how should the nurse respond?
you will not look exactly the same but cosmetic surgery will help.
a nurse administers topical gentamicin sulfate to a clients burn injury. which lab values should the nurse monitor while the client is prescribed this therapy?
creatinine
the nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?
sometimes I wake up at night and smoke
a nurse cares for an older client w/ burn injuries. which age-related changes are paired appropriately with their complications from the burn injuries?
-slower healing time increased risk for loss of nutrition from contracture formation -reduced thoracic compliance increased his for atelectasis -high incidence of cardiac impairments increased risk for acute kidney injury
a nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. how should the nurse document the percentage of the clients body that sustained burns?
27%
A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?
I will bathe and dress before breakfast.
a nurse teaches a client being treated for a full-thickness burn. which statement should the nurse include in the clients discharge teaching?
I will demonstrate how to change your wound dressing for you and your family.
a nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the parkland formula. the clients urine output continues to range from 0.2 to 0.25 ml/kg/hr. which prescription should the nurse question?
administer furosemide 40mg IV push.
a nurse cares for a client with burn injuries. which intervention should the nurse implement to appropriately reduce the clients pain?
administer the prescribed intravenous morphine sulfate.
an emergency room nurse assesses a client who was rescued from a home fire. the client suddenly develops a loud, brassy cough. which action should the nurse take first?
apply oxygen and continuous pulse oximetry.
a nurse cares for a client with a brain injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
auscultate breath sounds over the trachea and bronchi.
The nurse is caring for a client with an acute brain injury. Which action should the nurse take to prevent infection by auto-contamination?
change gloves between wound care on different parts of the clients body.
a nurse cares for a client with burn injuries from a house fire. the client is not consistently oriented and reports a headache. which action should the nurse take?
draw blood for a carboxyhemoglobin level.
a nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours late the wheezing is no longer heard. which action should the nurse take?
gather appropriate equipment and prepare for an emergency airway.
a nurse prepares to administer intravenous cimetidine to a client who has a new brain injury. the client asks, why am I taking this medication? how should the nurse respond?
it helps prevent stomach ulcers, which are common after burns
The nurse assesses a client who has a severe burn injury. which statement indicates the client understands the psychosocial impact of a severe brain injury?
it is normal to feel some depression.
a nurse delegates hydrotherapy to an unlicensed assistive personnel. which statement should the nurse include when delegating this activity?
keep the water temperature constant when showering the client.
A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. which action should the nurse take next?
place the client in an upright position
a nurse reviews the lab results for a client who was burned 24 hours ago. which lab result should the nurse report to the health care provider immediately?
serum potassium 6.5
