Iggy Chapter 26: Care of Patients with Burns

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. "Administer the prescribed tetanus toxoid vaccine." b. "Assess the client's wounds for signs of infection." c. "Encourage the client to breathe deeply every hour." d. "Wash your hands on entering the client's room."

d. "Wash your hands on entering the client's room."

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. "It is normal to feel some depression." b. "I will go back to work immediately." c. "I will not feel anger about my situation." d. "Once I get home, things will be normal."

a. "It is normal to feel some depression."

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. "Keep the water temperature constant when showering the client." b. "Assess the wound beds during the hydrotherapy treatment." c. "Apply a topical enzyme agent after bathing the client." d. "Use sterile saline to irrigate and clean the client's wounds."

a. "Keep the water temperature constant when showering the client."

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement.

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

a. 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? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.

a. Apply oxygen and continuous pulse oximetry.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospital's gift shop. e. Use aseptic technique and wear gloves when performing wound care.

a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. e. Use aseptic technique and wear gloves when performing wound care.

A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

a. Creatinine

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control

a. Music as a distraction b. Tactile stimulation e. Increasing client control

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

a. Provide at least 5000 kcal/day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time - Increased risk for loss of function from contracture formation b. Reduced inflammatory response - Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance - Increased risk for atelectasis d. High incidence of cardiac impairments - Increased risk for acute kidney injury e. Thinner skin - May not exhibit a fever when infection is present

a. Slower healing time - Increased risk for loss of function from contracture formation c. Reduced thoracic compliance - Increased risk for atelectasis d. High incidence of cardiac impairments - Increased risk for acute kidney injury

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.

b. Administer furosemide (Lasix) 40 mg IV push.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

b. Change gloves between wound care on different parts of the client's 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? a. Increase the client's oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the client's intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.

b. Draw blood for a carboxyhemoglobin level.

The nurse is caring for a patient who is admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care? a. Assess and treat pain. b. Evaluate airway and circulation. c. Place two IV catheters and initiate fluid resuscitation. d. Use the rule of nines to estimate percent of body surface area burned.

b. Evaluate airway and circulation.

It has been 12 hours since a patient has been admitted for burns to the face and neck with associated inhalation injuries. The patient had been wheezing audibly and the wheezing has now stopped. What nursing action is appropriate? a. Check the patient's Spo2 level. b. Notify the physician immediately. c. Re-assess breathing in 1 hour. d. Document improvement in patient's condition.

b. Notify the physician immediately. Notify the physician immediately if the patient with an inhalation injury becomes more breathless or audible wheezes disappear. This could indicate a worsening of the patient's respiratory injuries, including possible loss of the patient's airway.

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? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6° F (38° C)

b. Urine output of 20 mL/hr

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. "I will allow my spouse to change my dressings." b. "I want to have surgical reconstruction." c. "I will bathe and dress before breakfast." d. "I have secured the pressure dressings as ordered."

c. "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 this client's discharge teaching? a. "You should change the batteries in your smoke detector once a year." b. "Join a program that assists burn clients to reintegration into the community." c. "I will demonstrate how to change your wound dressing for you and your family." d. "Let me tell you about the many options available to you for reconstructive surgery."

c. "I will demonstrate how to change your wound dressing for you and your family."

A nurse cares for a client who has burn injuries. The client's wife asks, "When will his high risk for infection decrease?" How should the nurse respond? a. "When the antibiotic therapy is complete." b. "As soon as his albumin levels return to normal." c. "Once we complete the fluid resuscitation process." d. "When all of his burn wounds have closed."

d. "When all of his burn wounds have closed."

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, "Why am I taking this medication?" How should the nurse respond? a. "Tagamet stimulates intestinal movement so you can eat more." b. "It improves fluid retention, which helps prevent hypovolemic shock." c. "It helps prevent stomach ulcers, which are common after burns." d. "Tagamet protects the kidney from damage caused by dehydration."

c. "It helps prevent stomach ulcers, which are common after burns."

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. "I get my chimney swept every other year." b. "My hot water heater is set at 120 degrees." c. "Sometimes I wake up at night and smoke." d. "I use a space heater when it gets below zero."

c. "Sometimes I wake up at night and smoke."

A nurse cares for a client who has facial burns. The client asks, "Will I ever look the same?" How should the nurse respond? a. "With reconstructive surgery, you can look the same." b. "We can remove the scars with the use of a pressure dressing." c. "You will not look exactly the same but cosmetic surgery will help." d. "You shouldn't start worrying about your appearance right now."

c. "You will not look exactly the same but cosmetic surgery will help."

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 client's body that sustained burns? a. 9% b. 18% c. 27% d. 36%

c. 27%

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

c. Auscultate breath sounds over the trachea and bronchi.

A nurse reviews the following data in the chart of a client with burn injuries: Based on the data provided, how should the nurse categorize this client's injuries? Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial

c. Full thickness

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L

c. Serum potassium: 6.5 mEq/L

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowler's position. d. Gather appropriate equipment and prepare for an emergency airway.

d. Gather appropriate equipment and prepare for an emergency airway.

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? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

d. Place the client in an upright position.

A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient's white blood cell count has dropped significantly over the past 4 days. How does the nurse interpret this finding? a. Electrolyte imbalance b. Infection is improving c. Impending kidney disease d. Possible allergic reaction to silver sulfadiazine (Silvadene)

d. Possible allergic reaction to silver sulfadiazine (Silvadene) During therapy with silver sulfadiazine (Silvadene), a drop in the patient's white blood cell count indicates an allergic reaction. Silvadene does not cause kidney disease, infection, or electrolyte imbalance.