Burns
A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? Record your answer as a whole number.
250mL *RATIONALE: *2,000 mL ÷ 8 hours = 250 mL/hour
A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required? "I will not hold my infant while drinking coffee." "I will heat my infant's formula in the microwave." "I will set my water heater to 49° C (120° F)."hot "I will keep loose appliance cords tied up on the counter."
"I will heat my infant's formula in the microwave. Rationale: Infant formula should never be heated in the microwave; the formula may heat at different temperatures and can burn the infant's mouth. Plastic bottle liners may also burst with the heat. Setting your hot water heater a couple of degrees cooler will help keep hot water in the house cooler (recommended since 1974 by the Consumer Product Safety Commission). Small children are at risk for scald injury from hot tap water due to their decreased reaction time, their curiosity, and the thermal sensitivity of their skin. Avoiding holding infants while drinking coffee can prevent possible spills onto children. Keeping cords tied up on the counter prevents children from pulling on dangling cords and spilling hot liquids over themselves.
A client has received burns to the anterior and posterior lower extremities. In order to calculate the expected amount of fluid resuscitation, the nurse calculates the client's percentage of body area burned as what percent? Record your answer using a whole number
36 Rationale: Using the Rule of Nines, the clients surface area that has been burned is calculated as 9% for the anterior surface of the left leg, 9% for the posterior surface of the left leg, 9% for the anterior surface of the right leg, and 9% for the posterior surface of the right leg = 9% X 4 or 36%
A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.
36. Rationale: The anterior and posterior portions of one leg are 18%, if both legs are burned, the total is 36
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? An electrocardiogram (ECG) showing no arrhythmias. A weight gain of 4 lb (2 kg) in 24 hours. Body temperature readings all within normal limits. A urine output consistently above 40 ml/hour (40 mL/hour).
A urine output consistently above 40 ml/hour (40 mL/hour. Rationale: n a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb (70 kg) client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb (2 kg) weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.
A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath?
Administer an analgesic. Rationale: 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 before hand
A client with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which of the following actions action should the nurse take? Assess the client's blood pressure. Assess oxygen saturation using pulse oximetry. Administer lorazepam 4 mg IV. Administer morphine sulfate 2 mg IV
Assess oxygen saturation using pulse oximetry. Rationale: Confusion, anxiety, restlessness, and disorientation are signs of hypoxemia. Due to the recent fire and burn injuries, the client may have suffered an inhalation injury that could be causing hypoxia. Administration of medication may be indicated once hypoxemia or other medical causes are ruled out.
While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next? Notify the physician that the wound may be infected. Continue to monitor the suture line, and document findings. Apply normal saline solution to keep the wound moist. Prepare the client for debridement of the suture line.
Continue to monitor the suture line, and document findings Rationale: During the fibrinoplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. This normal occurrence requires the nurse to continue to monitor the suture line. There is no evidence of wound dehiscence or necrotic tissue. There is also no indication that the wound is open or needs to be kept mois
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst. Urine output of 70 ml the first hour. Moderate to severe pain. Hoarseness of the voice
Hoarseness of the voice Rationale: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.
The nurse in the emergency department is caring for a 12-year-old child with full-thickness, circumferential burns to the chest, and has difficulty breathing. What is the priority intervention? Intubation. Escharotomy. Chest tube insertion. Needle thoracocentesis
Intubation. Rationale: Intubation is performed to maintain a patent airway Escharotomy is a surgical incision used to relieve pressure from edema. It's needed with circumferential burns that prevent chest expansion or cause circulatory compromise. Insertion of a chest tube and needle thoracocentesis are performed to relieve a pneumothorax.
The client has a continuous bladder irrigation after a transurethral resection. A major goal related to the irrigation is to: Recognize signs of prostate cancer. Reduce incisional bleeding. Perform activities of daily living. Maintain catheter patency.
Maintain catheter patency. Rationale: Maintaining catheter patency during the immediate postoperative period after a transurethral resection is a priority because postoperative bleeding can occlude the catheter. Catheter occlusion can lead to urine retention, pain, bladder spasm, and the need to replace the catheter. Incisional bleeding is not expected unless a complication occurs. The client in the immediate postoperative period is not ready for teaching about the signs of prostate cancer. Performing activities of daily living, such as bathing, is not a priority immediately after surgery.
A client had an appendectomy 2 days ago and is now presenting with purulent drainage, pain in the mid-incision, and a temperature of 101.3°F (38.5°C). What would be the most appropriate action by the nurse? No action is necessary because these are normal findings. Administer acetaminophen and reassess in 2 hours. Notify the surgeon as soon as possible. Ambulate the client in the hall.
Notify the surgeon as soon as possible. Rationale: The client is exhibiting signs of a wound infection, which results in systemic temperature elevation. The drainage of purulent exudate also indicates a wound infection. The other choices are not appropriate actions at this time.
A client is brought to the emergency department having been involved in a fire while putting lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be dry and pale white with some areas that are brown and leathery. Which of the following types of burns does the nurse determine are present?
Third degree (full thickness) Rationale: Third-degree burns involve the epidermis, dermis, and sometimes subcutaneous tissue. They are insensate and usually present as dry, pale, white, red brown, leathery, or charred. First degree or superficial burns involve the outer layer of the skin and are similar to sunburn, reddened without blisters. Second degree burns or partial thickness burns involve the dermis and have a reddened, blistered appearance. Fourth degree burns involve the dermal layers as well as the fat, fascia, muscle, and may also include bone.
A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: promote drainage of wound exudates. provide access for wound irrigation. minimize the development of scar tissue. decrease postoperative discomfort.
promote drainage of wound exudates Rationale: Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.
The nurse is caring for a teenage client on a burn unit who has sustained third-degree burns over 40% of the body. A family member asks why the client isn't reporting of more pain. Which of the following is the best response by the nurse?
"The severe burns have damaged nerves that sense pain." Rationale: Full-thickness burns damage nerve endings and initially may feel somewhat painless. Regeneration of the nerve endings in recovery may cause significant pain. Confusion, adequate pain medication, and burns that are not deep enough would not be the most likely explanation of the client's lack of reports of pain.
The nurse administers 1500 ml of Lactated Ringers over six hours to a 12-year-old child with partial and full thickness burns over 40% of his body. How many milliliters per hour should this child receive? Record your answer using a whole number.
250mL Rationale: 1500/6=250
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? 18% 9% 36% 27%
27% Rationale: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body
A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? a. Initiating an antibiotic within 3 hours of the injury. b. Infusion of dextrose and water at 50 mL per hour to avoid overload of the circulatory system. c.A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. c.Monitoring urine output once a shift
A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. Rationale: A client with electrical burns based on energy and potential damage to the heart needs cardiac monitoring. Dextrose is not useful for fluid volume expansion and infection would occur much later. Urine output needs hourly monitoring based on myoglobin release.
A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated?
Administer pain medication 30 minutes before therapy to help manage pain. Rationale: Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for pain about 30 minutes before the treatment in anticipation of the increased pain the client will experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session. However, electrolyte loss can occur from open wounds during immersion, so the sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy unless it is an individualized need for a given client. Topical antibiotics are applied after hydrotherapy
When teaching the diabetic client about foot care, what should the nurse instruct the client to do?
Avoid going barefoot. Rationale: The client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and decreased circulation. The client should be taught to avoid going barefoot to prevent injury. Shoes that do not fit properly should not be worn because they will cause blisters that can become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight across. A heating pad should not be used because of the risk of burns due to insensitivity to temperature.
A nurse is providing wound care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. What should the nurse do to provide wound care? Remove the dressing and leave the incision open to air. Remove the drain if wound drainage is minimal. Clean the area around the drain moving away from the drain. Gently irrigate the drain to remove exudate.
Clean the area around the drain moving away from the drain. Rationale: The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.
During the recuperation phase, a client with severe burns has become withdrawn. What concerns should the nurse explore? Concerns regarding how the client's family will respond Concerns regarding dependence and unwillingness to be discharged Concerns regarding coping abilities. Concerns about body image and self esteem
Concerns about body image and self esteem. Rationale: During the recuperation phase, the client is likely to consider the body image implications of this injury. Sensitivity to body image and self-esteem issues are anticipated concerns. The client has suffered through the most difficult part. There are fewer concerns regarding dependence and coping abilities in the recuperation phase. The family will have been more concerned during the initial phase.
The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first? Have all visitors and family leave the room. Call the surgeon to come to the client's room immediately. Cover the abdominal organs with sterile dressings moistened with sterile normal saline. Press the emergency alarm to call the resuscitation team
Cover the abdominal organs with sterile dressings moistened with sterile normal saline. Rationale: When a wound eviscerates (abdominal organs protruding through the opened incision), the nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia. The nurse should not press the emergency alarm because this is not a cardiac or respiratory arrest. The nurse should have the visitors and family leave the room to decrease the chance of airborne contamination, but the primary focus should be on covering the wound with a moist, sterile covering.
When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order? Culture. Irrigation. Debridement Incision and drainage
Debridement Rationale: Necrotic tissue prevents wound healing and must be removed. This is accomplished by debridement. Incision and drainage, culture, or irrigation won't remove necrotic tissue. Incision and drainage drain a wound abscess. A wound culture indentifies organisms growing in the wound and helps the physician determine appropriate therapy. If the wound is infected, the physician may order irrigation — usually with an antibiotic solution — to treat the infection and clean the wound.
The nurse is caring for an eight-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? Applying topical antibiotics. Debriding and grafting the burns. Diluting the chemicals. Applying sterile dressings.
Diluting the chemicals. Rationale: It will help to remove the chemicals, and stop the burning process. The rest of the treatments are initiated after diluting the chemicals.
The client with a major burn injury receives total parenteral nutrition (TPN). What is the expected outcome of TPN? Correct water and electrolyte imbalances. Provide supplemental vitamins and minerals. Ensure adequate caloric and protein intake. Allow the gastrointestinal tract to rest.
Ensure adequate caloric and protein intake. Rationale: 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.
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, 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, what prescription should the nurse request from the health care provider? furosemide IV rate increase fresh frozen plasma dextrose 5%
IV rate increase Rationale: 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.
A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? Laterally, from the distal area to the center In a widening circle around the drain, outward from the center Laterally, from one side of the wound to the opposite side. From the superior portion of the wound to the inferior
In a widening circle around the drain, outward from the center Rationale: When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from top to bottom when cleaning a vertical incision.
The nurse is changing the dressing of a client after an abdominal hysterectomy. If the dressing adheres to the client's incisional area, what should the nurse do? Remove part of the dressing, and then remove the remainder gradually over a period of several minutes. Pull off the dressing quickly, and then apply slight pressure over the area. Moisten the dressing with sterile normal saline solution, and then remove it. Lift an easily moved portion of the dressing, and then remove it slowly.
Moisten the dressing with sterile normal saline solution, and then remove it. Rationale: When a dressing sticks to a wound, it is best to moisten the dressing with sterile normal saline solution and then remove it carefully. Trying to remove a dry dressing is likely to irritate the skin and wound. This may contribute to tension or tearing along the suture line.
A 23-month-old child pulls a pan of hot water off the stove and spills it onto her chest and arms. Her mother is right there when it happens. What should the mother do immediately? Place the child in a bathtub of cool water. Apply antibiotic ointment to the burned areas. Apply ice directly to the burned areas. Call the neighbor to come over and help her.
Place the child in a bathtub of cool water. Rationale: The emergency treatment of both minor and major burns includes stopping the burning process by immersing the burned area in cool, but not cold, water. Thus, the mother should place the child in a bathtub of cool water. Applying ice directly to the burned area is inappropriate at this time because more tissue damage can result. Antibiotic ointment should not be applied to the burned area at this time because the burning process must be stopped first. Calling a neighbor for help is appropriate after the mother has placed and then removed her child from the bathtub.
A nurse is assessing a client 2 days after surgery for infection. Which sign or symptom is most indicative of infection? The presence of pain at the incision site. Rectal temperature of 100° F (37.8° C). White blood cell (WBC) count of 8,000/μl. Red, warm, swollen, tender incision with foul drainage
Red, warm, swollen, tender incision with foul drainage Rationale: Redness, warmth, swelling, tenderness, and foul drainage in the incision area indicate a postoperative infection. Pain at the incision site would be expected on postoperative day 2. A rectal temperature of 100° F would be a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/μl. This client's WBC count falls within this normal range.
A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to infection Related to fat emboli Related to circumferential eschar Related to femoral artery occlusion
Related to circumferential eschar Rationale: As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.
A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority? Beginning range of motion exercises Preventing contractures of extremities Preparing for an escharotomy. Replacing fluid and electrolytes
Replacing fluid and electrolytes. Rationale: After establishing a patent airway, fluid resuscitation is critical for the client with a burn injury. Positioning to prevent contractures and removing dead skin (escarotomy) are important interventions, but are not the priority. It is too soon to begin range of motion exercises.
In a toddler, which injury is most likely the result of child abuse? A 1-inch forehead laceration. A hematoma on the occipital region of the head. Several small, dime-sized circular burns on the child's back . A small isolated bruise on the right lower extremity
Several small, dime-sized circular burns on the child's back. Rationale: Small circular burns on a child's back are no accident and may have been caused by cigarettes. Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries aren't uncommon. A small area of ecchymosis isn't suspicious in this age-group.
What should be a priority for a 6-year-old child admitted with third-degree burns? Start an IV line. Insert an indwelling urinary (Foley) catheter. Obtain baseline laboratory studies. Administer prescribed antibiotics orally.
Start an IV line. RATIONALE: The child will need fluid replacement therapy as soon as possible, primarily due to the shift of plasma from intravascular to interstitial spaces at burn sites. Blisters and edema resulting from this process lead to fluid and electrolyte loss. Severe burns are usually sterile. Antibiotic treatment, if used at all, would not be a priority at this time. Insertion of an indwelling urinary (Foley) catheter would be done once the intravenous line is started. Laboratory studies would be drawn after the intravenous line is started.
A client who has had a bowel resection comes to the health center 7 days postoperatively for removal of the staples. As the nurse is cleansing the incision, the client reports of mid-incision pain. After removing three staples, the nurse observes that the incision is separating. What is the nurse's priority action? Apply warm compresses to the painful area before removing the remaining staples. Stop the staple removal, cover the incision, and report the findings to the physician. Apply butterfly tapes to the separated area and redress the wound immediately. Remove the remaining staples, apply butterfly tapes, and document the findings.
Stop the staple removal, cover the incision, and report the findings to the physician. Rationale: If there are signs of dehiscence while removing staples, it is important to stop the removal of staples and to dress the open wound. It is very important to relay the observations of mid-incision pain and separation of the wound to the physician as soon as possible. Continuing the staple removal is not appropriate. A dehiscence presenting with other signs of pain could indicate the presence of an abscess. It is not enough to apply butterfly tapes. The observations need to be relayed to the physician.
Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation? Skin intact over bony prominences. Staples intact to the incision. Minimal serous wound drainage. A temperature of 102° F (38.9°C
Temperature of 102° F (38.9°C) Rationale: A variance is a deviation from what is expected on a critical pathway. An elevated temperature is a variance on the third postoperative day. A nurse must report the finding to the physician, who must determine source of the fever. Minimal serous drainage, intact skin over bony prominences, and intact staples are expected on the third post-operative day.
The nurse is performing triage in the emergency department. Which client should be seen first?
The client with burns to his chest and neck with singed nasal hair. Rationale: The client with burns to the chest and neck has the potential to develop decreased lung expansion. Singed nasal hair is indicative of inhalation injury and delayed respiratory distress syndrome. Flank pain and open fractures will not take precedence over the client with airway problems. The primipara still has time before the baby comes.
The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder? To reduce abdominal pain through pressure support To maintain blood flow and circulation in the abdominal incision To assist in collection of wound drainage products from the incision To reduce stress on the abdominal incision
To reduce stress on the abdominal incision Rationale: Applying an abdominal binder will reduce further stress on the incision and prevent another dehiscence, thus allowing the skin and tissue to heal. The other choices are not accurate reasons to use a binder.
A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal? Transurethral resection of the prostate (TURP) Transurethral laser incision of the prostate. Retropubic prostatectomy. Suprapubic prostatectomy
Transurethral resection of the prostate (TURP) Rationale: TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially suitable for men with relatively minor prostatic enlargements and for those who are poor surgical risks. Suprapubic prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common procedures; each requires an incision.
When developing a teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing? scheduled periods of rest. adequate circulatory status. fluid intake of 1,500 mL/day. balanced nutritional diet
adequate circulatory status. Rationale: Adequate circulatory status is the most important factor in the healing process of an infected decubitus ulcer. Blood flow to the area must be present to bring nutrients and prescribed antibiotics to the tissues
When planning care for a group of clients, the nurse notes that which client is most susceptible to infection? a 42-year-old with a recent, uncomplicated appendectomy. an 86-year-old with burns from using a heating pad. a 6-year-old with a simple fracture of the femur. an 18-year-old with diabetes mellitus
an 86-year-old with burns from using a heating pad. Rationale: The very young and the elderly are more susceptible to infection. An elderly client with a break in skin integrity, such as the 86-year-old with a burn, is at an increased risk for infection. The 6-year-old does not have a compound fracture (protruding through the skin) and is not at high risk for infection. A client with an appendectomy is at risk for infection of the surgical site but not as high a risk as the client with burns. While a client with diabetes is at risk for infection, this adolescent is not at high risk at this time.
The nurse is assigning tasks to unlicensed assistive personnel (UAP) for a client with an abdominal hysterectomy on the first postoperative day. Which task cannot be delegated to the UAP? assessing the incision site. recording intake and output. giving perineal care. taking vital signs
assessing the incision site Rationale The registered nurse is responsible for monitoring the surgical site for the condition of the dressing, status of the incision, and signs and symptoms of complications. Unlicensed assistive personnel who have been trained to report abnormalities to the registered nurse supervising the care may take vital signs, record intake and output, and give perineal care.
A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to: wash the area with soap and water to disinfect it. apply a weakened alcohol solution to clean the area. clean the area with normal saline solution and cover it with a protective dressing. remove the raised skin because the blister has already broken.
clean the area with normal saline solution and cover it with a protective dressing. Rationale: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.
A client's abdominal incision eviscerates. The nurse should first: take the client's vital signs and call the health care provider (HCP). cover the incision with a dressing moistened with sterile normal saline solution. start an emergency infusion of IV fluids. lower the client's head and elevate the feet.
cover the incision with a dressing moistened with sterile normal saline solution. Rationale: When an incision eviscerates, it is a medical emergency. The nurse's first response is to apply a sterile dressing that has been moistened with sterile normal saline solution. The client should also be placed in semi-Fowler's position to release any tension on the abdominal area. Vital signs should be taken, and an IV line may be started for emergency treatment; however, the first action is to protect the wound and abdominal contents.
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: increase edema in the arms. increase the amount of scarring. decrease circulation to the fingers. dislodge the autografts.
dislodge the auto grafts. Rationale: Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: examination of the fundus of the eye. evaluation of bowel and bladder functions. assessment of the client's gait. evaluation of the corneal reflex response.
evaluation of the corneal reflex response. Rationale: During an acute crisis, the nurse should check the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in the arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't vital, so the nurse should delay their assessment.
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? every 5 minutes every 15 minutes every 10 minutes every 20 minutes
every 15 minutes Rationale: In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.
While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for: gastrointestinal ulceration. gastric distention. paralytic ileus. hiatal hernia.
gastrointestinal ulceration. Rationale: Also known as Curling's ulcer, occurs in about half of clients suffering from severe burns. The ulceration is proportional to the extent of the burns and due to hypersecretion of gastric acid and compromised gastrointestinal perfusion. Gastrointestinal ulceration, also known as Curling's ulcer, occurs in about half of clients suffering from severe burns. The incidence of ulceration appears proportional to the extent of the burns and is believed to be due to hypersecretion of gastric acid and compromised gastrointestinal perfusion. Paralytic ileus, gastric distention, and hiatal hernia are not caused by hypersecretion of gastric acid. Gastric distention is not caused by hypersecretion of gastric acid. Hiatal hernia is not caused by hypersecretion of gastric acid
Which finding is expected when the nurse is assessing a child who has sustained full-thickness burns? excessive bleeding minimal pain blanching to the touch blistering and a moist appearance
minimal pain Rationale: Full-thickness burns are serious injuries in which all the skin layers are destroyed. Lack of pain is characteristic of full-thickness burns. With full-thickness burns, blanching and bleeding are absent because blood supply is destroyed. Blisters and a moist appearance characterize partial-thickness burns.
Which action would be most helpful in preventing pressure ulcer formation in an at-risk client? massaging reddened areas on the sacrum repositioning every hour. ensuring a generous fluid intake. providing a low-protein diet
repositioning every hour Rationale Because pressure ulcers (decubitus ulcers) are caused by pressure to the tissues, the most important measure in preventing them is to relieve the pressure by repositioning the client every 1 to 2 hours. A low-protein diet will not prevent pressure ulcer formation. Rather, the client should receive a diet that ensures an adequate intake of calories and protein. While essential to ensure adequate hydration, a generous fluid intake alone will not prevent ulcer formation. The underlying cause is pressure. Massaging reddened areas and bony prominences, once thought to reduce risk of pressure ulcer formation, is now known to increase the risk of pressure ulcer formation.
The mother calls the nurse to report that her toddler just been burned on the arm. The nurse should advise the mother to first: pack the arm in ice, and then take the child to the closest emergency department. call the child's health care provider (HCP) immediately, and then wrap the arm in a clean cloth. run cool water over the burned area, and then wrap it in a clean cloth. rub the burned area with an antibacterial ointment, and then call the child'
run cool water over the burned area, and then wrap it in a clean cloth. Rationale: The best advice for the nurse to give the child's mother is to run cool water over the burned area to stop the burning process. Then the area should be wrapped in a clean cloth. Once these initial actions are completed, the mother can call the child's HCP. Packing the arm in ice may cause more damage to the burned area because cold can cause burns just as heat can. For most burns, it is not advised to apply ointment until the area has been evaluated.
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? serum albumin level of 3.8 g/dL (38 g/L). hourly urine output of 60 mL. serum creatinine level of 2.5 mg/dL (221 µmol/L). little fluctuation in daily weight
serum creatinine level of 2.5 mg/dL (221 µmol/L). Rationale: 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).
Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has
thermal burns to the head, face, and airway resulting in hypoxia. Rationale: 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.
