Burns

Which response by the nurse has the highest priority? "I will arrange for a counselor to come and visit with you." "Would you like to talk to another young man who was burned?" "I think you should talk to your parents about how you feel." "Have you thought about how you would kill yourself?"

"Have you thought about how you would kill yourself?"

According to Erikson, which statement by the client indicates that the client is achieving the tasks of his stage of growth and development? "I really wish my parents would stay with me all the time." "I do not like my friends coming to visit me in the hospital." "I really hate it when my mom kisses me in front of my friends." "I really don't care how I look as long as I can play soccer."

"I really hate it when my mom kisses me in front of my friends."

How should the nurse respond to client? "Of course I won't tell. I will honor your right to confidentiality" "If I'm concerned that it will affect your care, then I will have to tell someone." "Why wouldn't you want me to tell anyone?" "What you tell me won't leave this room. What would you like to tell me?" Submit

"If I'm concerned that it will affect your care, then I will have to tell someone."

The client is receiving an escharotomy to treat his burn complications. Which information is accurate for the nurse provide to his parents? "Your son has an infection that is causing his leg to swell." "Your son is experiencing a common complication of burns to the leg." "Don't worry about your son, everything is going to be all right." "The HCP will make an incision in his leg to relieve the pressure."

"The HCP will make an incision in his leg to relieve the pressure."

How should the nurse explain to the client the rationale for wearing these pressure garments? "These garments will help prevent your burns from becoming infected so they can heal." "You must wear the stockings if you do not want the grafts to separate." "The pressure stocking will help prevent scarring that could occur while the burn is healing." "This will help decrease itching as the wound heals."

"The pressure stocking will help prevent scarring that could occur while the burn is healing."

How should the nurse respond? "I will call your HCP so he can come explain it to you." "The graft will come from pig skin that is specially treated." "All of the skin used will come from the local tissue donation bank." "The skin will probably be taken from your son's back."

"The skin will probably be taken from your son's back."

The nurse determines that the client could use a PRN dose of morphine for his break through pain. The morphine is in a vial labeled 10 mg/mL. How much morphine will the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.) Submit

0.4 4 mg/X = 10 mg/mL4 = 10X4/10 = 0.4 mL

The nurse should document which percentage of body surface? 20%. 45%. 60%. 85%.

45%

Triage determines in what order a client is seen by a healthcare provider (HCP). Which of the following clients would the nurse identify with a red tag? (Select all that apply.) A client whose vital signs include respirations at 22 breaths/min, pulse at 120 beats/min, and blood pressure at 85/52 mmHg. A client with a pulsating femur wound. A client with full thickness burns over 50% of the body. A client with a crushing head injury. A client who is alert and oriented with a minor laceration to her forehead.

A client whose vital signs include respirations at 22 breaths/min, pulse at 120 beats/min, and blood pressure at 85/52 mmHg. A client with a pulsating femur wound. A client with full thickness burns over 50% of the body.

A burn injury such as the client's produces a profound metabolic need. The client requires sufficient nutrients for wound healing and increased metabolic demands. The client can take oral nutrients and requests an evening snack. Which snack is best for the nurse to provide? A refrigerated can of Ensure. A peanut butter sandwich. A bowl of regular Jell-O gelatin. Any type of fruit the client will eat. Submit Previous Section

A peanut butter sandwich.

Which action is included when a Level I disaster is declared? Radio stations interrupt broadcasting to declare a state of emergency. A statewide emergency response team is deployed to the accident site. Hospital staff from the county hospital report to the disaster site for triage. All local hospitals prepare to receive casualties.

All local hospitals prepare to receive casualties.

Cleaning the wound and preventing infection are priorities of care. The client is scheduled for daily total immersion hydrotherapy. Which intervention should the nurse implement during his hydrotherapy? (Select all that apply.) Active range of motion exercises of his extremities. Use a sterile blade to open any intact blisters during the bath. Schedule the client for at least 1 hour in the hydrotherapy bath to speed the healing process. Perform surgical debridement during the last 10 minutes of the bath. Wash burn areas thoroughly and gently with mild soap and water.

Active range of motion exercises of his extremities. Wash burn areas thoroughly and gently with mild soap and water.

The client will be in the hospital for at least 1 month. The multidisciplinary healthcare team discusses how to best meet his growth and development needs. Which interventions will meet the client's needs during his hospital stay? (Select all that apply.) Allow his parents to bring in CD's and video games. Allow the client to have any toys from home in his room. Encourage the client to wear his own personal clothes. Refer the client to the homebound school department. Inform the parents that a laptop computer with internet access would be good for their son's socialization needs.

Allow his parents to bring in CD's and video games. Inform the parents that a laptop computer with internet access would be good for their son's socialization needs.

The police officer then asks to see client's ED medical record. Which action should the nurse take concerning this request? Refer the police officer to the hospital medical records department. Inform the police officer that client's record is confidential. Allow the police officer access to the requested medical records. Explain that the officer must have a court subpoena to see the records.

Allow the police officer access to the requested medical records.

Fluid replacement is noted to be ideal if client produces how much output/hour? Urine is recorded as an hourly output of 1 mL/kg (1 mL/2.2 lbs). Urine is recorded as an hourly output of 10 mL/kg (10 mL/2.2 lbs). Urine is record as an hourly output of 20 mL/kg (20 mL/2.2 lbs). Urine is recorded as hourly output of 30 mL/kg (30 mL/2.2 lbs).

Urine is recorded as hourly output of 30 mL/kg (30 mL/2.2 lbs).

Which action is most important for the nurse to take before the assessment? Ask the parents to leave the room before obtaining information from the client. Direct all of the questions to the client's parents to allow him time to rest. Leave the form with the client and ask him to complete it at his convenience. Request that the social worker complete the psychosocial assessment.

Ask the parents to leave the room before obtaining information from the client.

Burn clients who surpass 20% Total Body Surface Area (TBSA) have massive shifts of fluid and electrolytes from intravascular to extravascular spaces, which can lead to cardiovascular collapse. Which assessment relates most directly to a diagnosis of Curling's ulcer? Assess peripheral pulses hourly with a Doppler ultrasound device. Monitor client's urine for hemoglobin and myoglobin. Assess the gastric aspirate for pH and blood the color of coffee grounds. Evaluate bony prominences and skin for any reddened areas.

Assess the gastric aspirate for pH and blood the color of coffee grounds.

Which action should the nurse implement to help these family members cope with this tragedy? Direct all family members to the local EDs immediately. Designate specific family areas that are staffed with counselors. Contact the American Red Cross to begin notifying immediate family members. Refer all family members to the police, who will provide essential information.

Designate specific family areas that are staffed with counselors.

Which action should be implemented to address this issue? Contact the local home healthcare agency. Request that one of the client's parents take a leave of absence from work. Determine if there is a family member who can stay with the client during the day. Discuss the possibility of the client staying at home alone.

Determine if there is a family member who can stay with the client during the day.

The nurse assesses both of the client's graft sites and notes that the gauze dressing over the donor site is moist and intact. What action should the nurse implement? Document this assessment in the client's chart. Evaluate the client's vital signs for a febrile reaction. Replace the moist dressing with a dry, sterile dressing. Check the linens to determine if any drainage is on the bed.

Document this assessment in the client's chart.

Which intervention has the highest priority? Administer all doses of any prescribed intravenous antibiotics. Ensure meticulous hand washing before and after the client's care. Monitor the client's white blood cell (WBC) count daily. Record oral intake and urinary output daily.

Ensure meticulous hand washing before and after the client's care.

The client has many physical, emotional, and psychosocial needs. Which intervention is most important for the nurse to implement upon admission? Attempt to locate his parents. Determine the depth and extent of his burns. Administer IV pain medication. Establish and maintain an open airway.

Establish and maintain an open airway.

While caring for a client who has burns, which nursing intervention is essential in minimizing client's potential for infection? (Select all that apply.) Advise the visitors that only immediate family members are allowed in the room. Inform the client's family members that plants and flowers are not allowed in his room. Provide a vase for his flowers, so they are kept hydrated throughout his stay. Provide visitors with isolation gowns and instruction in hand hygiene. Assess each visitor for any respiratory infection, and instruct them to wear a mask at all times.

Inform the client's family members that plants and flowers are not allowed in his room. Provide visitors with isolation gowns and instruction in hand hygiene.

Which action should the nurse take? Inform the officer that he must first speak to the client's parents. Ask the client if he feels up to speaking with the police officer. Explain to the officer that the client is not allowed to have visitors. Notify the house supervisor of the officer's request.

Inform the officer that he must first speak to the client's parents.

Which action should the nurse implement? Notify the HCP of this finding immediately. Outline the drainage on the dressing and write the date and time. Obtain stat serum hemoglobin and hematocrit levels. Remove the surgical dressing to assess the wound site directly.

Outline the drainage on the dressing and write the date and time.

Client grimaces in pain as the nurse assesses his red and blistered wounds that are affecting his epidermis and dermis. Based on this assessment, which finding best describes the his burns? Fourth degree burns. First degree burns. Partial thickness or second degree burns. Full thickness or third degree burns.

Partial thickness or second degree burns.

EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse implement first? Place a disaster tag securely on each victim. Communicate with the county emergency room. Determine which ambulance will transport which client. Identify a site for the casualties to be taken until identified.

Place a disaster tag securely on each victim.

The HCP has prescribed mafenide acetate for the client's burned areas for application to the burn wounds twice a day. Topical agents such as mafenide acetate solution that deeply penetrate tissue are used to cover the wound. To prepare the client for this treatment, which intervention should the nurse implement? Premedicate with an opioid analgesic 20 minutes prior to applying this medication. Assess the client for leukopenia before administering this medication. Protect the client's bed linen and clothing from contact with the medication. Evaluate the client's arterial blood gases for respiratory acidosis.

Premedicate with an opioid analgesic 20 minutes prior to applying this medication.

Which triage category should the nurse assign to client? Priority 1, Color Red. Priority 2, Color Yellow. Priority 3, Color Green. Priority 4, Color Black.

Priority 1, Color Red.

Which discharge preparation has the highest priority? Ask the grandmother to demonstrate the application and removal of the pressure garments. Provide specific written instructions for the client's home care before releasing him to go home. Assure the client's grandmother that she can call the rehabilitation unit anytime. Discuss homebound schooling with the family so that the client will not be delayed in school.

Provide specific written instructions for the client's home care before releasing him to go home.

Which action should the nurse implement? Discuss the client's concerns with his parents. Request a multidisciplinary team meeting. Notify the school nurse about the client's condition. Refer the client to an adolescent burn support group.

Refer the client to an adolescent burn support group.

Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the time the fluid is given to the client? The nurse administers the total calculated fluid in the first 8 hours upon arrival. The nurse administers the first half of the fluid calculated over 12 hours, and the second half over the next 12 hours. The nurse administers the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours. The nurse administers the fluid over 24 hours from the time the burn occurred.

The nurse administers the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours.