NDEE Exam 5 - Review

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? 1 Oral 2 Topical 3 Intravenous 4 Intramuscular

2 Topical

The nurse is caring for a client who has been admitted with partial- and full-thickness burns over 25% of the total body surface area. Lactated Ringer solution and 5% dextrose have been prescribed. What is the purpose of these fluids? 1 Prevent fluid shifts 2 Expand the plasma 3 Maintain blood volume 4 Replace electrolytes lost

3 Maintain blood volume

A nurse is caring for a client with diabetes insipidus. Which clinical manifestation should a nurse expect the client to exhibit? 1 Increased blood glucose 2 Decreased serum sodium 3 Increased specific gravity 4 Decreased urine osmolarity

4 Decreased urine osmolarity Insufficient antidiuretic hormone (ADH) decreases water uptake by the kidney tubules, resulting in very dilute urine with low osmolarity [1] [2]. Diabetes insipidus does not affect glucose levels; diabetes mellitus affects glucose levels. Serum sodium levels increase because of hemoconcentration. Specific gravity decreases with dilute urine.

A patient with a mild case of diabetes insipidus is started on Diabinese. What would you include in your patient teaching with this patient? A. Signs and symptoms of hypoglycemia B. Restricting foods containing caffeine C. Taking the medication on an empty stomach D. Drinking 16 oz of water when taking the medication

A. Signs and symptoms of hypoglycemia

Which of the following signs and symptoms is NOT expected with Diabetes Insipidus? A. Polyuria B. Polydipsia C. Polyphagia D. Extreme thirst

C. Polyphagia

The nurse is caring for a client 2 days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum? •Sooty •Frothy •Yellow •Tenacious

Sooty

Which hormones are secreted by the posterior pituitary gland? Select all that apply. 1 Oxytocin 2 Prolactin 3 Corticotropin 4 Antidiuretic hormone 5 Melanocyte-stimulating hormone

1 Oxytocin 4 Antidiuretic hormone Oxytocin and antidiuretic hormone (vasopressin) [1] [2] are secreted by the posterior pituitary gland. Prolactin, corticotropin, and melanocyte-stimulating hormones are secreted by the anterior pituitary gland.

A patient arrives to the ER and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly "water" weight. In addition, they report the patient hasn't been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient's HR is 115 and BP 180/92. Patient sodium level is 90. Which of the following conditions do you suspect the patient is most likely presenting with? A. SIADH B. Diabetes Insipidus C. Addison's Disease D. Fluid Volume Deficient

A. SIADH

Where is the anti-diuretic hormone PRODUCED in the body? A. Anterior pituitary gland B. Posterior pituitary gland C. Hypothalamus D. Medulla

C. Hypothalamus

A patient with SIADH is undergoing IV treatment of a hypertonic IV solution of 3% saline and IV Lasix. Which of the following nursing findings requires intervention? A. Sodium level of 136. B. Patient reports urinating more frequently. C. Potassium level of 5.0. D. Assessment finding of crackles throughout the lung fields.

D. Assessment finding of crackles throughout the lung fields.

Which hormone is released from the posterior pituitary gland? 1 Oxytocin 2 Prolactin 3 Growth hormone 4 Luteinizing hormone

1 Oxytocin Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland.

A client reports their lips feel thicker, as well as joint pain and coarse facial features. What should the nurse suspect as the cause of the anterior pituitary hyperfunction? 1 Excessive secretion of growth hormone 2 Excessive secretion of prolactin hormone 3 Excessive secretion of thyroid-stimulating hormone 4 Excessive secretion of adrenocorticotropic hormone

1 Excessive secretion of growth hormone Thickened lips, joint pain, and coarse facial features are the symptoms of acromegaly which is caused by pituitary gland hyperfunction leading to excessive secretion of growth hormone. Prolactin hormone hypersecretion can cause hypogonadism, which is loss of sexual characteristics. Thyroid-stimulating hormone hypersecretion can result in increases in both plasma thyroid-stimulating hormone and thyroid hormone levels. Adrenocorticotropic hormone hypersecretion can cause Cushing's disease characterized by increased plasma cortisol levels.

The nurse is caring for a client in labor whose medical report states posterior pituitary hormone deficiency. Which medication administration is required for the client considering the medical condition? 1 Oxytocin to promote uterine contractions 2 Prolactin to promote breast milk ejection 3 Luteinizing hormone to promote painless labor 4 Follicle-stimulating hormone to promote estrogen secretion

1 Oxytocin to promote uterine contractions Oxytocin is a posterior pituitary hormone that acts on the uterus to stimulate uterine contractions. Therefore the nurse should administer oxytocin to the client. Prolactin is an anterior pituitary hormone that promotes breast milk production, not milk ejection. Luteinizing hormone is an anterior pituitary hormone that stimulates progesterone secretion and ovulation and does not promote painless labor. Follicle-stimulating hormone is secreted by the anterior pituitary and is involved in estrogen secretion and follicle maturation.

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. Which response by the nurse is most appropriate? 1 The epidermis is damaged. 2 The dermis is damaged partially. 3 The structures beneath the skin are destroyed. 4 Both the epidermis and the dermis are destroyed

1 The epidermis is damaged.

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first? 1 Remove the client's clothing. 2 Evaluate whether the client has inhaled smoke. 3 Insert a venous access device in an unaffected arm. 4 Determine the extent of the burns, using the rule of nines.

2 Evaluate whether the client has inhaled smoke. Smoke inhalation can cause edema of the respiratory lumen, interfering with oxygenation; evaluation of respiratory status is the first, priority assessment. Venous access facilitates administration of parenteral medications and fluids that may be urgently needed, but it is not the first action. Removing the client's clothing should be done after the client's respiratory status is evaluated. Determining the extent of the burns, using the rule of nines, should be done after the client's respiratory status is evaluated.

A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply. 1 Soot on legs 2 Brassy cough 3 Deep breathing 4 Singed nasal hair 5 Dark mucous membranes

2 Brassy cough 4 Singed nasal hair 5 Dark mucous membranes A brassy cough is indicative of possible pulmonary damage caused by an inhalation burn. Singed nasal hair indicates possible pulmonary damage. Dark mucous membranes are a sign of potential respiratory insufficiency that results from inhalation burns. Sputum will be sooty; sooty legs is not an indication. Deep breathing indicates metabolic acidosis, not respiratory insufficiency.

The nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction? 1 Deep breathing 2 Hoarse quality to the voice 3 Pink-tinged, frothy sputum 4 Rapid abdominal breathing

2 Hoarse quality to the voice Hoarseness is a sign of potential respiratory insufficiency as a result of inhalation injury, which causes edema in the surrounding tissues, including the vocal cords. Sputum will be sooty, not frothy; pink-tinged, frothy sputum is associated with pulmonary edema. Deep breathing and rapid abdominal breathing indicate metabolic acidosis, not respiratory insufficiency.

The nurse is assessing a client who reports frequent urination. Which inquiry made by the nurse will help determine diabetes insipidus? 1 "Do you have history of cancer?" 2 "Are you on fluoroquinolone therapy?" 3 "Are you on lithium carbonate therapy?" 4 "Do you have a history of lymphoma?"

3 "Are you on lithium carbonate therapy?" Lithium carbonate is known to interfere with normal kidney response to antidiuretic hormone. Therefore enquiring about lithium carbonate therapy can help assess for diabetes insipidus, which has a clinical manifestation of frequent urination. Inquiry about history of cancer helps in assessing syndrome of inappropriate antidiuretic hormone (SIADH) because some cancer therapy drugs result in SIADH. Treatment with fluoroquinolone antibiotics also can result in SIADH. Hodgkin's and Non-Hodgkin's lymphoma are causes of SIADH.

A client is brought to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. To assess for heat inhalation, the nurse first should observe for which finding? 1 Changes in the chest x-ray findings 2 Sputum that contains particles of blood 3 Nasal discharge containing carbon particles 4 Changes in the arterial blood gases consistent with acidosis

3 Nasal discharge containing carbon particles Singed nasal hair and nasal discharges that contain carbon are warning signs of respiratory inhalation. Changes in chest x-ray findings are a late sign of respiratory problems. Sputum that contains particles of blood may be a sign of pneumonia or tuberculosis. Changes in arterial blood gases are late signs of respiratory problems.

A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. What should the nurse assess for in this client? 1 Dehydration 2 Dry brittle hair 3 Prolonged wound healing 4 Clubbing of the fingertips

3 Prolonged wound healing Adequate intake of protein, carbohydrates, vitamin C, and minerals is necessary for tissue building and wound healing. There are no data to indicate dehydration; although the client is not eating, the client may be drinking fluids. Dry brittle hair will take a prolonged period of time; it will not occur during a short period. Clubbing of the fingertips is associated with prolonged hypoxia.

A nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent? 1 Colitis 2 Gastritis 3 Stress ulcer 4 Metabolic acidosis

3 Stress ulcer An ulcer of the upper gastrointestinal tract is related to excessive secretion of stress-related hormones, which increases hydrochloric acid production. Histamine H2 antagonists decrease acid secretion. Colitis is not a complication of burns. Gastritis is not a complication of burns. Metabolic acidosis is not a complication of burns unless hypermetabolism or renal failure occurs; metabolic acidosis is not treated with H2 antagonists.

A carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm again and I'll be scarred forever." Which initial response by the nurse is best? 1 "The staff is taking steps to minimize scarring." 2 "Think about how lucky you are. You are alive." 3 "Try not to worry for now. Concentrate on your range-of-motion exercises." 4 "I know you're worried, but it is too early to tell how much scarring will occur."

4 "I know you're worried, but it is too early to tell how much scarring will occur." The response "I know you're worried, but it is too early to tell how much scarring will occur" is a truthful answer and validates the client's feelings. Although true, the response "The staff is taking steps to minimize scarring" shuts off communication and further ventilation of feelings. The response "Think about how lucky you are. You are alive" denies the client's fears. The response "Try not to worry for now. Concentrate on your range-of-motion exercises" denies the client's feelings and changes the subject.

A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. What is the nurse's priority intervention? 1 Administering oxygen 2 Inserting a urinary catheter 3 Giving prescribed pain medication 4 Starting an intravenous line with a large-bore catheter

4 Starting an intravenous line with a large-bore catheter Because of the location and degree of burns, an IV line for fluid restoration and access for pain medications is the priority. Oxygen is not needed because the airway is not involved and oxygen deprivation has not been identified. The insertion of a urinary catheter is a secondary action after fluid administration begins. Although giving pain medication is important, an IV infusion for fluid restoration to prevent hypovolemic shock is the priority. Pain medication for both children and adults with burns usually is administered through an IV catheter.

You are developing a care plan for a patient with SIADH. Which of the following would be a potential nursing diagnosis for this patient? A. Fluid volume overload B. Fluid volume deficient C. Acute pain D. Impaired skin integrity

A. Fluid volume overload

The anti-diuretic hormone is __________ in Diabetes Insipidus and _________ in SIADH. A. high, low B. absent, absent C. low, high D. low, low

C. low, high

In the scenario above what drug do you anticipate the patient will be started on per doctor's order? A. Desmopressin (DDAVP) IV B. Declomycin C. Diabinese D. Stimate

B. Declomycin

The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client? A. Current range of motion in all extremities B. Heart rate and rhythm C. Respiratory rate and pulse oximetry reading D. Orientation to time, place, and person

B. Heart rate and rhythm Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. It is also important to obtain the patient's cardiac history, including any history of prior arrhythmias. Option A: Range of motion is also important. However, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs. Option C: The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Any patient that was in contact with a high voltage source should have continuous cardiac monitoring during evaluation. Option D: These patients are specifically at risk for cardiac damage if the path of the current traversed the heart. One may also consider CT imaging of the head if the patient has altered mental status or associated head trauma from a fall or being thrown in a blast.

The client who is burned is drooling and having difficulty swallowing. Which action will the nurse take first? A. Assesses level of consciousness and pupillary reactions B. Ascertains the time food or liquid was last consumed C. Auscultates breath sounds over the trachea and mainstem bronchi D. Measures abdominal girth and auscultates bowel sounds

C. Auscultates breath sounds over the trachea and mainstem bronchi Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. The absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation.

At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? A. Immediately following the injury B. During the fluid shift C. During fluid remobilization D. During the late acute phase

C. During fluid remobilization Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output. In an attempt to prevent hypokalemia it is advised to add '20-30 mEq/1 of potassium to the hypotonic fluids in order to compensate for urinary losses and intracellular shift; it is also mandatory to correct precipitating factors such as increased pH, hypomagnesemia, and several drugs.

The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? A. Seasonal asthma B. Hepatitis B 10 years ago C. Myocardial infarction 1 year ago D. Kidney stones within the last 6 month

C. Myocardial infarction 1 year ago It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation.

The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury? A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Full-thickness deep

C. Partial-thickness deep Deep partial-thickness burns are pink or red in color, swollen, painful, with blisters that may ooze a clear fluid. Deep partial-thickness (second-degree) involves the deeper dermis. Healing occurs in 3 to 8 weeks with scarring present. Option A: Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Option B: The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is red; without blisters and pain present. Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days. Option D: Blisters are not seen with full-thickness burns and are rarely seen with deep partial-thickness burns. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

Where is the anti-diuretic hormone SECRETED in the body? A. Hypothalamus B. Thyroid C. Posterior Pituitary gland D. Anterior pituitary gland

C. Posterior Pituitary gland

When should ambulation be initiated in the client who has sustained a major burn? A. When all full-thickness areas have been closed with skin grafts B. When the client's temperature has remained normal for 24 hours C. As soon as possible after wound debridement is complete D. As soon as possible after the resolution of the fluid shift

D. As soon as possible after the resolution of the fluid shift Regular, progressive ambulation is initiated for all burn clients who do not have contraindicating concomitant injuries as soon as the fluid shift resolves. Clients can be ambulated with extensive dressings, open wounds, and nearly any type of attached lines, tubing, and other equipment.

The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse's best action? A. Nothing, because the findings are normal for clients during the acute phase of recovery. B. Increase the temperature in the room and increase the IV infusion rate. C. Assess the client's airway and oxygen saturation. D. Notify the burn emergency team.

D. Notify the burn emergency team. These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention. Invasive infection of burn wounds is a surgical emergency because of the high concentrations of bacteria (>105 CFU) in the wound and surrounding area, together with new areas of necrosis in unburned tissues.

A nurse is caring for a client newly admitted with a diagnosis of pheochromocytoma. Which clinical findings does the nurse expect when assessing this client? Select all that apply. 1 Headache 2 Palpitations 3 Diaphoresis 4 Bradycardia 5 Hypotension

1 Headache 2 Palpitations 3 Diaphoresis A pounding headache is secondary to the severe hypertension associated with excessive amounts of catecholamines. Palpitations are associated with stimulation of the sympathetic nervous system caused by catecholamines (epinephrine and norepinephrine). Diaphoresis is associated with stimulation of the sympathetic nervous system because of excessive catecholamines. Tachycardia, not bradycardia, is associated with stimulation of the sympathetic nervous system caused by catecholamines. Hypertension, not hypotension, is the principal clinical manifestation associated with pheochromocytoma because of stimulation of the sympathetic nervous system.

What is the action of the vasopressin hormone released from the client's posterior pituitary? 1 Helps produce concentrated urine 2 Causes tubular secretion of sodium 3 Promotes potassium secretion in the collecting duct 4 Enhances sodium reabsorption in the distal convoluted tubule

1 Helps produce concentrated urine The action of the hormone vasopressin released from the posterior pituitary is to make the distal convoluted tubule and collecting duct permeable to water so as to maximize reabsorption and produce concentrated urine. The natriuretic hormones produced from cardiac ventricles cause tubular secretion of sodium. Aldosterone released from the adrenal cortex promotes potassium secretion and sodium reabsorption in the distal convoluted tubules and collecting duct.

A nurse is assessing a client admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify? 1 Retention of sodium and water 2 Hypotension and a rapid, thready pulse 3 Increased fatty deposition in the extremities 4 Hypoglycemic episodes in the early morning

1 Retention of sodium and water Increased levels of steroids and aldosterone cause sodium and water retention in clients with Cushing syndrome. Hypertension, not hypotension, is expected because of sodium and water retention. The extremities will be thin; subcutaneous fat deposits occur in the upper trunk, especially the back between the scapulae. Hyperglycemia, not hypoglycemia, occurs because of increased secretion of glucocorticoids. Hyperglycemia is sustained and not restricted to the morning hours.

A 3-year-old child is admitted with partial- and full-thickness burns over 30% of the body. What significant adverse outcome during the first 48 hours should the nurse attempt to prevent? 1 Shock 2 Pneumonia 3 Contractures 4 Hypertension

1 Shock The immediate postburn period is marked by dramatic changes in fluid and electrolyte balance. Alterations in electrolyte balance can produce confusion, weakness, cardiac irregularities, and seizures. As a result of large fluid losses through the denuded skin, vasodilation, and edema formation, hypovolemic shock may develop. Pneumonia is a later complication associated with immobility. Contractures are a later complication associated with scarring and aggravated by improper positioning and splinting. Hypotension, not hypertension, occurs with hypovolemic shock.

A nurse is caring for a 7-year-old child with severe burns who has extensive eschar formation on the arms. What is the priority nursing intervention? 1 Removing blisters 2 Checking radial pulses 3 Maintaining respiratory isolation 4 Performing range-of-motion exercise

2 Checking radial pulses

A client undergoes removal of a pituitary tumor through a transsphenoidal approach. What should the nurse implement postoperatively? 1 Provide oral hygiene and include brushing the teeth 2 Encourage the client to deep breathe and cough frequently 3 Maintain the head of the bed at a 30-degree angle continuously 4 Continue giving nothing by mouth until the nasal packing is removed

3 Maintain the head of the bed at a 30-degree angle continuously Maintaining the head of the bed at a 30-degree angle continuously decreases pressure on the sella turcica and promotes venous return, thus limiting cerebral edema. Gentle oral hygiene is performed, excluding brushing of teeth, to prevent trauma to the surgical site. Although deep breathing is encouraged, initially coughing is discouraged to prevent increasing intracranial pressure. There is no need to limit oral fluids because of the presence of nasal packing.

Which patient is most at risk for developing Syndrome of Inappropriate Anti-diuretic Hormone (SIADH)? A. A patient diagnosed with small cell lung cancer. B. A patient whose kidney tubules are failing to reabsorb water. C. A patient with a tumor on the anterior pituitary gland. D. A patient taking Declomycin.

A. A patient diagnosed with small cell lung cancer.

Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? A. Colloids B. Crystalloids C. Fresh-frozen plasma D. Packed red blood cells

B. Crystalloids Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringer's lactate. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted.

Nurse Malcolm is performing a sterile dressing change on a client with a superficial partial-thickness burn on the shoulder and back. Arrange the steps in the order in which each should be performed. - Administer Tramadol (Tramal) 50 mg IV. - Obtain a sample for wound culture. - Debride the wound of eschar using gauze sponges. - Apply silver nitrate ointment. - Cover the wound using a sterile gauze dressing.

- Administer Tramadol (Tramal) 50 mg IV. - Debride the wound of eschar using gauze sponges. - Obtain a sample for wound culture. - Apply silver nitrate ointment. - Cover the wound using a sterile gauze dressing. Pain medication is administered prior to the dressing change since the type of burn will be painful during the procedure. Opioids may be required initially to control pain, but once first aid measures have been effective non-steroidal anti-inflammatory drugs such as ibuprofen or co-dydramol taken orally will suffice. Then the wound is debrided before getting the sample for culture to prevent other bacteria that can contaminate the actual wound. It is important to realize that a new burn is essentially sterile, and every attempt should be made to keep it so. The burn wound should be thoroughly cleaned with soap and water or mild antibacterial wash such as dilute chlorhexidine. Obtain a sample for wound culture. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury An antibacterial cream such as silver nitrate is applied to the area to attain the maximum effect of the medication. Flamazine is silver sulfadiazine cream and is applied topically on the burn wound. It is effective against gram-negative bacteria including Pseudomonas. Lastly, cover the wound using a sterile dressing. Depending on how healing is progressing, dressing changes thereafter should be every three to five days. If the Jelonet dressing has become adherent, it should be left in place to avoid damage to the delicate healing epithelium. If Flamazine is used it should be changed on alternate days.

A nurse is assessing a client with diabetes insipidus. Which signs indicative of diabetes insipidus should the nurse identify when assessing the client? Select all that apply. 1 Excessive thirst 2 Increased blood glucose 3 Dry mucous membranes 4 Increased blood pressure 5 Decreased serum osmolality 6 Decreased urine specific gravity

1 Excessive thirst 3 Dry mucous membranes 6 Decreased urine specific gravity As excessive fluid is lost through urination, dehydration triggers the thirst response. As excessive fluid is lost through urination, dehydration occurs, resulting in dry mucous membranes and poor skin turgor. Because water is not being reabsorbed, urine is dilute, resulting in a low specific gravity (less than 1.005). Diabetes insipidus is not a disorder of glucose metabolism; blood glucose levels are not affected. Diabetes mellitus affects glucose metabolism. Loss of fluid may decrease the blood pressure because fluid is lost from the intravascular compartment. As fluid is lost from the intravascular compartment, serum osmolarity increases, not decreases.

A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first? 1 Start the time of the test after discarding the first voiding. 2 Discard the last voiding in the 24-hour time period for the test. 3 Insert a urinary retention catheter to promote the collection of urine. 4 Strain the urine following each voiding before adding the urine to the container

1 Start the time of the test after discarding the first voiding. The first voiding is discarded because that urine was in the bladder before the test began and should not be included. The last voiding should be placed in the specimen container because the urine was produced during the 24-hour time frame of the test. Discarding the last void in the 24-hour time period for the test is not necessary; voided specimens are acceptable. Straining the urine following each voiding before adding the urine to the container is not necessary; this is done for clients with renal calculi.

A 2½-year-old child is admitted to the hospital with deep partial-thickness burns involving the face and chest. The nurse bases a plan of care on concerns related to the child's injury. Place the following concerns in their order of importance. 1.Disturbed fluid balance 2. Impaired gas exchange 3. Compromised body image 4.Potential for infection 5. Presence of pain

1.Impaired gas exchange 2.Disturbed fluid balance 3.Presence of pain 4.Potential for infection 5.Compromised body image A compromised airway may occur with burns to the face and chest as a result of inhalation of hot gases and smoke, which cause mucosal damage and edema. Because of the fluid and electrolyte losses during the first 24 to 36 hours and the resulting shift of electrolytes, fluid and electrolyte balance become a priority after airway maintenance and pain management. Deep partial-thickness burns are painful; pain management is a priority after maintenance of a patent airway and promotion of gas exchange. Prevention of infection becomes a priority after airway maintenance, pain management, and maintenance of fluid and electrolyte balance; the potential for infection increases as the post injury timeframe progresses because of the damaged dermis. Body image becomes more of a priority after immediate physiologic needs have been met.

On the second day after sustaining extensive severe burns a 6-year-old child exhibits edema and decreased urine output. For which additional adverse response should the nurse assess the child in this early stage of burn injury? 1 Bradycardia 2 Disorientation 3 Subnormal temperature 4 Systolic blood pressure of 100 mm Hg

2 Disorientation Disorientation may be an initial indication of dehydration or an early sign of hypoxia resulting from respiratory complications. Tachycardia, not bradycardia, is usually associated with the early phases of burn injury. A fever, not a subnormal temperature, is associated with burns because of the increased basal metabolic rate. The systolic blood pressure range for a 6-year-old child is 95 to 110 mm Hg.

A school-aged child is admitted to the hospital with severe burns on the arms. Therapeutic escharotomy is planned. What is the priority nursing action at this time? 1 Removing blisters 2 Monitoring radial pulses 3 Maintaining airborne precautions 4 Performing passive range-of-motion exercises

2 Monitoring radial pulses Eschar is rigid and may restrict circulation and lead to loss of limb perfusion. Blisters are associated with superficial and deep partial-thickness burns; eschar is associated with full-thickness burns. Blisters are not removed because they protect the underlying skin. Maintaining airborne precautions is unnecessary; the client is not the source of infection but must be protected from infection because the first line of defense has been compromised. Performing passive range-of-motion exercises is unnecessary.

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall? 1 Partial-thickness burns require grafting before they can heal. 2 Partial-thickness burns are often painful, reddened, and have blisters. 3 Partial-thickness burns cause destruction of both the epidermis and dermis. 4 Partial-thickness burns often take months of extensive treatment before healing.

2 Partial-thickness burns are often painful, reddened, and have blisters. Pain is from the loss of the protective covering of the nerve endings; blisters and redness occur because of the injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only the epidermis and only part of the dermis. Recovery from partial-thickness burns with no infection occurs in 2 to 6 weeks.

A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication? 1 Place the medication directly on the dressing in a thick layer using clean gloves. 2 Place the medication directly on the burn wound in a thin layer using sterile gloves. 3 Put the medication in a Hubbard tank and saturate sterile dressings with it before applying the dressings to the burns. 4 Put the medication in a Hubbard tank and allow the client to soak in the tank for several minutes every day

2 Place the medication directly on the burn wound in a thin layer using sterile gloves. Sterile aseptic technique is necessary for an open wound, and a thin layer of ointment is applied directly to the affected area. Surgically aseptic, not medically aseptic, technique is used. Although some medications may be placed directly in the tank, antimicrobial medications are placed directly on the affected area using surgically aseptic technique.

The primary healthcare provider suspects pituitary gland dysfunction in a female client. Which diagnostic test would the primary healthcare provider suggest to the client? 1 Estradiol test 2 Prolactin test 3 Sims-Huhner test 4 Papanicolaou (Pap) test

2 Prolactin test A prolactin test is used to detect pituitary gland dysfunction that causes amenorrhea. Therefore the primary healthcare provider would suggest that the client have a prolactin test to determine if the client does or does not have any pituitary gland dysfunction. Estradiol is tested to determine functioning of the ovaries. In men, the estradiol test is used to detect testicular tumors. The Sims-Huhner test is used to evaluate the hostility of the cervix for passage of sperm from the vagina into the uterus. The Papanicolaou (Pap) test detects malignancies, particularly cervical cancer.

A 6-year-old child has partial-thickness burns of the face and upper chest. What is the priority nursing assessment for the first 24 hours? 1 Wound sepsis 2 Pulmonary distress 3 Fear and separation anxiety 4 Fluid and electrolyte imbalance

2 Pulmonary distress Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia resulting from irritation and edema of the respiratory passages and lungs. Although wound sepsis is a possible complication, it will not be evident until the third to fifth day. Although the child is probably fearful, maintaining a patent airway is the priority. This child is too old for separation anxiety; however, complications related to stress may occur later. Fluid losses may be extremely high but reach their maximum about the fourth day; the initial priority is maintaining a patent airway.

What is the action of vasopressin? 1 Promotes sodium reabsorption 2 Reabsorbs water into the capillaries 3 Promotes tubular secretion of sodium 4 Stimulates bone marrow to make red blood cells

2 Reabsorbs water into the capillaries Vasopressin is also known as an antidiuretic hormone (ADH). It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells (RBCs).

A nurse is assessing a client with a suspected pituitary tumor. Which assessment finding is consistent with a pituitary tumor? 1 Tetany 2 Seizures 3 Lethargy 4 Hyperreflexia

2 Seizures Seizures are common in clients who have pituitary tumors. Tetany is associated with severe hypocalcemia; that condition can be caused by hypoparathyroidism. Lethargy is found in clients with hypothyroidism. Hyperreflexia is observed in clients with hyperthyroidism and hypoparathyroidism.

Which finding would the nurse expect in the urinalysis report of a client with diabetes insipidus? 1 pH of urine: 9 2 Specific gravity of urine: 0.4 3 Red blood cells in urine: 6 hpf 4 White blood cells in urine: 8 hpf

2 Specific gravity of urine: 0.4 The normal specific gravity of urine lies between 1.003 and 1.030. The specific gravity of urine of clients with diabetes insipidus is low due to the impaired functioning of antidiuretic hormone. The pH of normal urine ranges from 6.5 to 7.0. A pH higher than 8 indicates a urinary tract infection (UTI). Normal urine contains between 0 and 4 hpf of red blood cells (RBCs). A count greater than 4 hpf indicates tuberculosis, cystitis, neoplasm, and glomerulonephritis. In a normal urine sample, white blood cells (WBCs) lie in the range of 0 to 5 hpf. Any increase in the number of WBCs indicates a urinary tract inflammation.

The nurse is assessing a client who reports frequent urination. Which inquiry made by the nurse will help determine diabetes insipidus? 1 "Do you have history of cancer?" 2 "Are you on fluoroquinolone therapy?" 3 "Are you on lithium carbonate therapy?" 4 "Do you have a history of lymphoma?"

3 "Are you on lithium carbonate therapy?" Lithium carbonate is known to interfere with normal kidney response to antidiuretic hormone. Therefore enquiring about lithium carbonate therapy can help assess for diabetes insipidus, which has a clinical manifestation of frequent urination. Inquiry about history of cancer helps in assessing syndrome of inappropriate antidiuretic hormone (SIADH) because some cancer therapy drugs result in SIADH. Treatment with fluoroquinolone antibiotics also can result in SIADH. Hodgkin's and Non-Hodgkin's lymphoma are causes of SIADH.

A 10-year-old child who was rescued from a house fire is brought to the emergency department with burns of the extremities. During assessment of the child, what finding is of most concern to the nurse? 1 Increased temperature 2 Increasing activity level 3 Burns around the mouth 4 Edema distal to the burns

3 Burns around the mouth Burns around the mouth indicate that the child may have inhalation burns; respiratory tract injury may result in edema, causing an airway obstruction. An increase in temperature indicates the presence of an infection; it is too early for an infection to occur. Increased activity is promising because it indicates that the burns were not severe. Edema distal to burns of the extremities is an expected finding.

In the immediate period after admission to the burn unit with severe burns, a 5-year-old child requests a drink of milk. What is the most appropriate nursing intervention? 1 Giving ice chips as desired 2 Permitting milk if it has been iced 3 Maintaining NPO status for 24 to 48 hours 4 Limiting oral fluid to 15 mL every 4 hours

3 Maintaining NPO status for 24 to 48 hours Nothing-by-mouth (NPO) status is maintained during the early emergency/resuscitative phase because of the probability of paralytic ileus. It is unsafe to offer ice chips because the fluid that is ingested interferes with monitoring and control of the child's fluid and electrolyte status. It is unsafe to offer oral fluids, not only because of the danger of paralytic ileus but also because they interfere with monitoring and control of the child's fluid and electrolyte status.

A nurse is transferring a client with a diagnosis of pheochromocytoma from the bed to a chair. What is the most important nursing intervention associated with this procedure for this client? 1 Supporting the client on the weak side 2 Ensuring that the chair is close to the client's bed 3 Placing sturdy shoes with rubber soles on the client's feet 4 Having the client sit on the side of the bed for a few minutes before the transfer

4 Having the client sit on the side of the bed for a few minutes before the transfer Having the client sit on the side of the bed for several minutes allows time for the blood pressure to adjust to the vertical position; this avoids dizziness and the potential for fainting or falling. The nurse should stand in front of the client to provide support when transferring any client from the bed to a chair. Once the client is safely standing, the client can walk to a chair in the room no matter where it is positioned. Although sturdy shoes with rubber soles are ideal when transferring a client from the bed to a chair, it is not the priority.

A client is diagnosed with pheochromocytoma. Which finding in the urinalysis report supports the diagnosis? 1 Sodium - 200 mmol/24 hr 2 Calcium - 5.6 mmol/24 hr 3 Urea nitrogen - 0.5 mmol/24 hr 4 Total catecholamines - 640 mmol/24 hr

4 Total catecholamines - 640 mmol/24 hr Total catecholamines increase in pheochromocytoma, stress, neuroblastoma, and heavy exercise. A total catecholamine level below 591 mmol/24 hr is normal. The client's report shows 640 mmol/24 hr of total catecholamines, which is higher than the normal range. Therefore the total catecholamine levels in the client's urinalysis report suggest pheochromocytoma. Sodium concentrations in the range of 40-220 mmol/24 hr are normal. The client has a sodium concentration of 200 mmol/24 hr, which is a normal finding. The normal levels of calcium in the urine range between 2.5-7.5 mmol/kg/24 hr. The client has a calcium concentration of 5.6 mmol/24 hr, which is a normal value. The normal values of urea nitrogen range from 0.43 to 0.71 mmol/24 hr. The client has a urea nitrogen of 0.5 mmol/24 hr, which is a normal finding.Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

Nurse Kelsey is a nurse manager assigned to the burn unit. Which client is best to assign to an RN who has floated from the surgery unit? A. A client with infected partial-thickness back and chest burns who has a dressing scheduled. B. A client who has just been admitted with burns over 30% of the body after a warehouse fire. C. A client with full-thickness burns on both arms who needs assistance in positioning hand splints. D. A client who requires discharge teaching about nutrition and wound care after having skin grafts.

A. A client with infected partial-thickness back and chest burns who has a dressing scheduled. Familiarity with the dressing change and practice of sterility by a nurse from the surgery unit will be appropriately used during the float in the burn unit. There are several options for burn dressings. Some are impregnated with antimicrobials (eg, silver). Most are a form of gauze, but there are biosynthetic dressings with some of the characteristics of skin that adhere to the wound and can be left in place for extended periods of time. Option B: Admission assessment requires expertise in caring for burn patients. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care. Option C: Splinting requires expertise in caring for burn patients. The staff members' levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for. Option D: Discharge teaching requires expertise in caring for burn patients. Validated and documented competencies must also be considered prior to assignment of patient care. No aspect of care can be assigned or delegated to another nursing staff member unless this staff member has documented evidence that they are deemed competent by a registered nurse to do so.

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury? A. Allowing the client to eat whenever he or she wants B. Beginning parenteral nutrition high in calories C. Limiting calories to 3000 kcal/day D. Providing a low-protein, high-fat diet

A. Allowing the client to eat whenever he or she wants Clients should request food whenever they think that they can eat, not just according to the hospital's standard meal schedule. Ascertain food likes and dislikes. Encourage SO to bring food from home, as appropriate. This provides the patient or SO a sense of control; enhances participation in care and may improve intake. Option B: Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications. Total parenteral nutrition (TPN) maintains nutritional intake and meets metabolic needs in presence of severe complications or sustained esophageal or gastric injuries that do not permit enteral feedings.

Ten hours after the client with 50% burns is admitted, her blood glucose level is 142 mg/dL. What is the nurse's best action? A. Document the finding B. Obtains a family history of diabetes C. Repeats the glucose measurement D. Stop IV fluids containing dextrose

A. Document the finding Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma. Option B: A family history of diabetes could make her more of a risk for the disease, but this is not a priority at this time. The secondary assessment shouldn't begin until the primary assessment is complete; resuscitative efforts are underway; and lines, tubes, and catheters are placed. Option C: The glucose level is not high enough to warrant retesting. A variety of laboratory tests will be needed within the first 24 hours of a patient's admission (some during the initial resuscitative period and others after the patient is stabilized). Option D: The cause of her elevated blood glucose is not the IV fluid. Rapid and aggressive fluid resuscitation is needed to replace intravascular volume and maintain end-organ perfusion.

Rehabilitation is the final phase of burn care. Which of the following are the goals during this phase?Select all that apply. A. Provide emotional support. B. Prevent hypovolemic shock. C. Promote wound healing and proper nutrition. D. Fluid replacement. E. Help the client in gaining optimal physical functioning.

A. Provide emotional support. C. Promote wound healing and proper nutrition. E. Help the client gain optimal physical functioning. The rehabilitation phase starts after wound closure and ends upon discharge and beyond. The goals of this phase include minimizing functional loss, promoting psychosocial support, promoting wound healing, and proper nutrition. Option A: Patients may try to refuse treatment as they are in pain and may not fully understand the impact of not participating in their rehabilitation; they, therefore, need the support and encouragement of the burn care professionals to help them through this difficult experience with the knowledge of how different their quality of life can be. Option B: Inflammatory and vasoactive mediators such as histamines, prostaglandins, and cytokines are released causing a systemic capillary leak, intravascular fluid loss, and large fluid shifts. These responses occur mostly over the first 24 hours peaking at around six to eight hours after injury. This can be managed with aggressive fluid resuscitation and close monitoring for adequate, but not excessive, IV fluids. Option C: Continuous monitoring and reassessment of nutritional status with modifications in nutritional therapy as indicated can accommodate the unique yet diverse needs of this population and support their therapeutic goals for recovery. Option D: Belong to the main goal during the resuscitative phase. Patients with burns of more than 20% - 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent "burn shock." Option E: A comprehensive rehabilitation program is essential to decrease a patient's post-traumatic effects and improve functional independence. While different professionals possess expertise in their own specialties, there are some simple and effective methods that can be utilized to help the patient reach their maximum functional outcome.

A client is being discharged today after undergoing autografting. What would the nurse include in the discharge instructions? A. Refrain from using splints. B. Avoid smoking. C. Exposed the site to sunlight. D. Encourage weight-bearing exercise.

B. Avoid smoking. Smoking can decrease the blood supply to the newly graft recipient bed interface, and the chance of graft failure increases. The combined effect of nicotine and carbon monoxide is deadly to the healing process. This can result in partial or complete loss of healing of the wound, skin graft, flap, or any combination of these. This can compromise the cosmetic results of the surgery. Option A: Static or primary splints are used in the acute phase for skin graft protection after surgery or anti contracture positioning. These splints are applied to adjacent intact skin. Option C: Healed burns or skin grafts may be extremely sensitive to sunlight and may sunburn more severely even after short periods of time in the sun compared to before the injury. Sun sensitivity after a burn injury may last for a year or more. Option D: At least 3 weeks after surgery, avoid exercise that stretches the skin graft, unless the doctor gives other instructions. If the graft was placed on the legs, arms, hands, or feet, the patient may need physiotherapy to prevent scar tissue from limiting movement.

Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action? A. Administers a laxative B. Documents the finding C. Increases the IV flow rate D. Repositions the client onto the right side

B. Documents the finding Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this time. Option A: Do not give the patient laxative. The emergent phase starts with the onset of burn injury and lasts until the completion of fluid resuscitation or a period of about the first 24 hours. During the emergent phase, the priority of patient care involves maintaining an adequate airway and treating the patient for burn shock. Option C: Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during the initial 24-72 hr after burn injury. Fluid replacement formulas partly depend on admission weight and subsequent changes. Option D: Maintain proper body alignment with supports or splints, especially for burns over joints. This promotes functional positioning of extremities and prevents contractures, which are more likely over joints.

The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness

B. Partial-thickness superficial The characteristics of the wound meet the criteria for a superficial partial-thickness injury (color that is pink or red; blisters; pain present and high). Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring. Option A: Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days. Option C: Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present. Option D: Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire? A. Pulse oximetry reading of 80% B. Expiratory stridor and nasal flaring C. Cherry red color to the mucous membranes D. Presence of carbonaceous particles in the sputum

C. Cherry red color to the mucous membranes The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a "cherry red" color of the mucous membranes in these clients. Cherry-red skin color associated with severe carbon monoxide poisoning is seen in only 2-3% of symptomatic cases. Skin may develop erythematous lesions and bulla, especially over bony prominences.

Nurse Faith should recognize that fluid shift in a client with burn injury results from an increase in the: A. Total volume of circulating whole blood B. Total volume of intravascular plasma C. Permeability of capillary walls D. Permeability of kidney tubules

C. Permeability of capillary walls In burn, the capillaries and small vessels dilate, and cell damage causes the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.

Which client factors should alert the nurse to potential increased complications with a burn injury? A. The client is a 26-year-old male. B. The client has had a burn injury in the past. C. The burned areas include the hands and perineum. D. The burn took place in an open field and ignited the client's clothing.

C. The burned areas include the hands and perineum. Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome. Complications are related to the extension of the burn. Burns to the genitalia and perineum are severe conditions that all urologists should be familiar with and know how to manage. Fluid resuscitation is the initial step in treating these patients and is followed by topical dressings in the case of superficial burns.

The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? A. The medication will be effective more quickly than if given intramuscularly. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced D. The client delayed gastric emptying.

C. The danger of an overdose during fluid remobilization is reduced The most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. Option A: Providing some pain relief has a high priority and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect. Pain that is more severe and not well controlled may be manageable with single or continuous doses of IV, epidural, and intrathecal formulations. Infusion dosing can vary significantly between patients and largely depends on how naive or tolerant they are to opiates. Option B: Respiratory depression is among the more serious adverse reactions with opiate use that is especially important to monitor in the postoperative patient population. Extreme caution is necessary with severe respiratory depression and asthma exacerbation cases since morphine can further decrease the respiratory drive. Option D: Delayed gastric emptying is not a side effect of morphine. Among the more common unwanted effects of morphine use is constipation. This effect occurs via stimulation of mu-opioid receptors on the myenteric plexus, which in turn inhibits gastric emptying and reduces peristalsis.

The client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which is the nurse's best action? A. Continuing to monitor the client B. Increasing the temperature in the room C. Increasing the rate of the intravenous fluids D. Preparing to do a workup for sepsis

D. Preparing to do a workup for sepsis These findings are associated with systemic gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Option A: Continuing just to monitor the situation can lead to septic shock. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies. Option B: Increasing the temperature in the room may make the client more comfortable, but the priority is finding out if the client has sepsis and treating it before it becomes a shock situation. Option C: Increasing the rate of intravenous fluids may be done to replace fluid losses with diarrhea, but is not the priority action. Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Replacement formulas vary but are based on the extent of injury, amount of urinary output, and weight.