Burns

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? a. Age of the client b. Associated medical history c. Location of the burn d. Cause of the burn

c. Location of the burn

A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take? a. Apply ice to the burns b. Place the child in a tub of cool water c. Pour tepid water over the burns d. Cover the burns with a blanket

c. Pour tepid water over the burns

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? a. Assign assistive personnel to keep his room neat and clean b. Rotate nursing staff so he can have varied interactions c. Talk with the client during wound care d. Keep family members aware of his condition

c. Talk with the client during wound care

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? a. Airway obstruction b. Infection c. Fluid imbalance d. Paralytic ileus

a. Airway obstruction

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? a. "Large incisions will be made in the eschar to improve circulation." b. "This procedure involves placing the client into a shower and removing the dead tissue." c. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area." d. "Dead tissue will be non-surgically removed."

a. "Large incisions will be made in the eschar to improve circulation."

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? a. Urinary output 25 mL/hr b. Difficulty swallowing c. Heart rate 122/min d. Pain of 6 on a scale of 0 to 10

b. Difficulty swallowing

A nurse in an emergency room is caring for a 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? a. Insert an indwelling urinary catheter b. Inspect the mouth for signs of inhalation injuries c. Administer intravenous pain medication d. Draw blood for a complete blood cell (CBC) count

b. Inspect the mouth for signs of inhalation injuries

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)? a. 9 percent b. 18 percent c. 36 percent d. 54 percent

d. 54 percent

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 hrs following a burn injury? a. Dextrose 5% in water b. Dextrose 5% in 0.9% sodium chloride c. 0.9% sodium chloride d. Lactated Ringer's

d. 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? a. Initiate fluid resuscitation b. Medicate for pain c. Insert an indwelling urinary catheter d. Maintain the airway

d. 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? a. Auscultate cuff blood pressure b. Palpate pulse pressure c. Obtain central venous pressure d. Monitor the pulmonary artery pressure

d. Monitor the pulmonary artery pressure