Custom: Burns Practice

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Difficulty swallowing

A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

Sensitive to touch Wound blanches with pressure Blisters

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

Hyperkalemia

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?

Erythema

A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Inspect the mouth for signs of inhalation injuries.

A nurse is teaching a client who is receiving radiation therapy about skin care. Which of the following instructions should the nurse include?

Walk outside in the early mornings.

A nurse is conducting a health promotion class for clients and their children about sun protection. The nurse should identify which of the following client responses as an indication that the teaching was effective?

"I will avoid sitting in the sun between 10 a.m. and 3 p.m."

A nurse is teaching a client about the uses of aloe vera. Which of the following information should the nurse include in the teaching?

"Aloe vera can act as a laxative."

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

Administer IV fluids.

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Airway obstruction

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?

Decreased serum calcium level

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury?

Lactated Ringer's

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury?

Maintain the airway.

A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

Monitor the pulmonary artery pressure.

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

Stop the treatment if the client's skin becomes red.

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Talk with the client during wound care.

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?

The burned area is red in color with eschar present.

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Location of the burn

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Use a transfer device to life the client up in bed.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

31.5

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned?

54

A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. The client suspects the snake to be venomous. Which of the following interventions should the nurse take?

Place the extremity in a dependent position.

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

The client who has gastroenteritis and is febrile.

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply.)

Vitamin A Vitamin B12 Vitamin C Vitamin K