Exam 2
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should: 1. Count the rate to be sure that ventilations are deep enough to be sufficient. 2. Notify the physician of the client's breathing pattern. 3. Increase the rate of ventilations. 4. Increase the tidal volume on the ventilator.
2. Notify the physician of the client's breathing pattern. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the physician immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen and the depth of breathing is assisted by the ventilator. The health care provider will determine changes in the ventilator settings
The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? 1. The head of the bed elevated 30 to 45 degrees. 2. Trendelenburg's position. 3. Left Sims' position. 4. The head elevated on two pillows.
1. The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. Sims' position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.
An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? 1. Establishing an airway. 2. Replacing blood loss. 3. Stopping bleeding from open wounds. 4. Checking for a neck fracture.
1. The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition? 1. Widening pulse pressure. 2. Decrease in the pulse rate. 3. Dilated, fixed pupils. 4. Decrease in level of consciousness (LOC)
4. A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.
During the emergent (resuscitative)phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation? A) Serum creatinine level of 2.5 mg/ dL (221 μmol/ L). B) Little fluctuation in daily weight. C) Hourly urine output of 60 mL. D) Serum albumin level of 3.8 (38 g/ L).
A. Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/ h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/ dL (35 to 50 g/ L).
In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? A) Oral analgesics such as ibuprofen (Motrin) or acetaminophen (Tylenol). B) Intravenous opioids. C) Intramuscular opioids. D) Oral antianxiety agents such as lorazepam (Ativan).
B The severe pain experienced by burn clients requires opioid analgesics. In addition, opioids such as morphine sedate and alleviate apprehension. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be strong enough to effectively manage the intense pain experienced by the client who is severely burned. Because of the altered tissue perfusion from the burn injury, intravenous medications are preferred . Antianxiety agents are not effective against pain.
After the initial phase of the burn injury, the client's plan of care will focus primarily on: A) Helping the client maintain a positive self-concept. B) Promoting hygiene. C) Preventing infection. D) Educating the client regarding care of the skin grafts.
C The inflammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There are a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate during the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection.
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: A) Encourage the formation of tough skin. B) Promote the growth of epithelial tissue C) Provide for permanent wound closure. D) Facilitate the development of subcutaneous tissue.
B Biologic dressings such as porcine grafts serve many purposes for a client with severe burns. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth of subcutaneous tissue.
During the early phase of burn care, the nurse should assess the client for? A) Hypernatremia. B) Hyponatremia. C) Metabolic alkalosis. D) Hyperkalemia.
D. Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of sodium bicarbonate.
The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. 1. Systolic blood pressure. 2. Urine output. 3. Breath sounds. 4. Cerebral perfusion pressure. 5. Level of pain.
1, 4 The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.
Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem? 1. Slow, irregular respirations. 2. Rapid, shallow respirations. 3. Asymmetric chest excursion. 4. Nasal flaring.
1. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.
A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? _______________mm Hg. 80mm Hg To obtain the MAP, use this formula: MAP = [systolic BP + (2 x diastolic BP)] ÷ 3 MAP = [120 + (2 x 60)] ÷ 3 MAP= 240 ÷ 3 = 80 A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. Whatshould the nurse do next? Select all that apply. 1. Find a television so the client can view the football game. 2. Determine if the client's pupils are equal and react to light. 3. Ask the client if he has a headache. 4. Arrange for the client to be with his wife and baby. 5. Administer a sedative.
2, 3 The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP.
Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube? A client who has: 1. Electrical burns of the hands and arms causing arrhythmias. 2. Thermal burns to the head, face, and airway resulting in hypoxia 3. Chemical burns on the chest and abdomen. 4. Secondhand smoke inhalation.
B. Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.
A client is admitted to the hospital after sustaining burns to the chest, abdomen , right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," estimate what percentage of the client's body surface has been burned. A) 18%. B) 27%. C) 45%. D) 64%.
C According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.
The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which of the following indicates that the client is responding to the fluid resuscitation? A) Pulse rate of 112. B) Blood pressure of 94/ 64. C) Urine output of 30 mL/ h. D) Serum sodium level of 136 mEq/ L (136 mmol/ L).
C Ensuring a urine output of 30 to 50 mL/ h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: A) Correct water and electrolyte imbalances. B) Allow the gastrointestinal tract to rest. C) Provide supplemental vitamins and minerals. D) Ensure adequate caloric and protein
D Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate . Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of IV fluids with electrolyte additives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vitamins and minerals ; however, the primary reason for starting TPN is to provide the protein necessary for tissue healing.
The nurse is conducting a focused assessment of the gastrointestinal system of a client with a burn injury . The nurse should assess the client for: A) Paralytic ileus B) . 2. Gastric distention. C) Hiatal hernia. D) Curling's ulcer.
D Curling's ulcer, or gastrointestinal ulceration, occurs in about half of the clients with a burn injury. The incidence of ulceration appears proportional to the extent of the burns, and the ulceration is believed to be caused by hypersecretion of gastric acid and compromised gastrointestinal perfusion. Paralytic ileus and gastric distention do not result from hypersecretion of gastric acid and stress. Hiatal hernia is not necessarily a potential complication of a burn injury.
The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. 1. Encourage the client to cough to expectorate secretions. 2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP is greater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of-motion exercises.
2, 3, 4 The nurse should maintain ICP by elevating the head of the bed and monitoring neurologic status. An ICP greater than 20 mm Hg indicates increased ICP, and the nurse should notify the health care provider. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.
Using the Parkland formula, calculate the hourly rate of fluid replacement with lactated Ringer's solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%. _______________ mL/ hour.
750 mL/hour. Lactated Ringer's solution 4 mL × weight in kg × TBSA; half given over the first 8 hours and half given over the next 16 hours.
The nurse should plan to begin rehabilitation efforts for the burn client: A) Immediately after the burn has occurred. B) After the client's circulatory status has been stabilized. C) After grafting of the burn wounds has occurred. D) After the client's pain has been eliminated.
B Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state ofhealth and independence . It is not possible to completely eliminate the client's pain; pain control is a major challenge in burn care.
The rate at which IV fluids are infused is based on the burn client's: A) Lean muscle mass and body surface area (BSA) burned. B) Total body weight and BSA burned. C) Total BSA and BSA burned. D) Height and weight and BSA burned.
B During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight . Total surface area is estimated by taking into account the individual's height and weight.
Which of the following factors would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? A) Absence of infection in the wounds. B) Adequate vascularization in the grafted area. C) Immobilization of the area being grafted D) . 4. Use of analgesics as necessary for pain relief.
D. Analgesic administration to keep a burn victim comfortable is important but is unlikely to influence graft survival and effectiveness. Absence of infection, adequate vascularization, and immobilization of the grafted area promote an effective graft.
A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? 1. Unequal pupil size. 2. Decreasing systolic blood pressure. 3. Tachycardia. 4. Decreasing body temperature.
1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? 1. Deep breathing. 2. Turning. 3. Coughing. 4. Passive range-of-motion (ROM) exercises.
3. Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.
A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will: 1. Exhibit no further episodes of short-term memory loss. 2. Be able to return to his construction job in 3 weeks. 3. Actively participate in the rehabilitation process as appropriate. 4. Be emotionally stable and display pre-injury personality traits.
3. Actively participate in the rehabilitation process as appropriate. Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client.
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg? 1. Give the client a warming blanket. 2. Administer low-dose barbiturates. 3. Encourage the client to hyperventilate. 4. Restrict fluids.
3. Encourage the client to hyperventilate. Normal ICP is 15 mm Hg or less or 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? 1. Compress the nares. 2. Tilt the head back. 3. Give the client tissues to collect the fluid. 4. Administer an antihistamine for postnasal drip.
3. Give the client tissues to collect the fluid. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.
A client has delirium following a head injury. The client is disoriented and agitated. In which order from first to last should the nurse do the following as a part of a plan to care for this client? 1. Request a prescription for haloperidol (Haldol) 2. Maintain a quiet environment. 3. Assure client's safety. 4. Approach the client using short sentences.
4,3,2,1 The first step in providing care for a client with delirium is to approach the client calmly, introduce oneself, and use short sentences when explaining the care given. The nurse should also assure the client's safety by protecting the client from injury. Maintaining a quiet and calm environment by removing extraneous noises will prevent overstimulation. Pharmacologic intervention is used only when other plans for care are not effective. When the underlying problems related to the head injury are resolved, the delirium likely will improve.
Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet. 3. Supination of arms, dorsifexion of the feet. 4. Back arched, rigid extension of all four extremities.
4. Back arched, rigid extension of all four extremities. Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.
Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing change? A) Soak the dressing. B) Remove the dressing. C) Administer an analgesic. D) Slit the dressing with blunt scissors.
C Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.
The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? 1. Muscle relaxation. 2. Intake and output. 3. Widening of the pulse pressure. 4. Pupil dilation
2. After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 36.2 ° C, heart rate 122 , blood pressure 84/ 42, Central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL /h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider with a recommendation for: A) Furosemide (Lasix). B) Fresh frozen plasma. C) IV rate increase. D) Dextrose 5%.
C The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding . Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.
When evaluating an arterial blood gas report from a client with a subdural hematoma who had surgery and is now on a ventilator, the nurse notes the PaCO2 is 35 mm Hg (4.7 kPa). The ventilator settings are: TV 400, respiration rate 24, FIO2 100%. What should the nurse do first? 1. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18. 2. Position the client with the head of bed elevated. 3. Continue to monitor the client. 4. Inform the charge nurse of the results of the report.
1. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Since the client's PaCO2 level is normal (35 to 45 mm Hg or 4.7 to 6.0 kPa), paging the respiratory technician to change the respiration rate is an appropriate action. Elevating the head of the client's bed is contradicted with this client's condition: that would lower blood pressure and care of these patients involves maintenance of a flat position in bed for 24 hours after surgery. Continuing to monitor the client is inappropriate because the PaCO2 level is normal and the respiratory technician needs to adjust the hyperventilation setting to normal on the ventilator since the lab indicates that PaCo2 is normal. Informing the charge nurse about the change in ventilator settings is not necessary at this time because this is expected care for this client.
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)? 1. Place in a jacket restraint. 2. Wrap the hands in soft "mitten" restraints. 3. Tuck the arms and hands under the drawsheet. 4. Apply a wrist restraint to each arm.
2. It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the drawsheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? 1. Keeping the client flat on one side or the other. 2. Elevating the head of the bed to 30 degrees. 3. Logrolling or turning as a unit when turning. 4. Keeping the neck in a neutral position.
2. Elevating the head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision, if not contraindicated by the increased intracranial pressure, is used for supratentorial craniotomies.
A client with a head injury regains consciousness after several days. Which of the following nursing statements is most appropriate as the client awakens? 1. "I'll get your family." 2. "Can you tell me your name and where you live?" 3. "I'll bet you're a little confused right now." 4. "You are in the hospital. You were in an accident and unconscious."
4. "You are in the hospital. You were in an accident and unconscious." It is important to first explain where a client is to orient him or her to time, person, and place. Offering to get the family and asking questions to determine orientation are important, but the first comments should let the client know where he or she is and what has happened. It is useful to be empathetic to the client, but making a comment such as "I'll bet you're a little confused" is not helpful and may cause anxiety.
There has been a fire in an apartment building. All residents have been evacuated , but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply. A) An 8-year-old with third-degree burns over 10% of his body surface area (BSA). B) A 20 -year-old who inhaled the smoke of the fire. C) A 50-year-old diabetic with first- and second-degree burns on his left forearm (about 5% of his BSA). D) A 30-year-old with second-degree burns on the back of his left leg. E) A 40-year-old with second-degree burns on his right arm (about 10% of his BSA).
A, B, C. Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA , clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.
The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? A) Clean the wounds with warm water. B) Apply antibiotic cream. C) Refer the client to a burn center. D) Cover the burns with a sterile dressing.
C The nurse should have the client transported to a burn center. The client's age and the extent of the burns require care by a burn team and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.
