med surg chapter 26

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.)

- Music as a distraction - Tactile stimulation - Increasing client control

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.)

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

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 clients body that sustained burns?

27%

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.)

- Administer analgesics. - Prevent wound infections. - Provide fluid replacement.

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.)

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

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?

Administer furosemide (Lasix) 40 mg IV push.

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain?

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?

Apply oxygen and continuous pulse oximetry.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?

Auscultate breath sounds over the trachea and bronchi.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?

Change gloves between wound care on different parts of the clients body.

A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy?

Creatinine

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?

Draw blood for a carboxyhemoglobin level.

- 36-year-old female with bilateral leg burns - 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. - NKDA - Health history of asthma and seasonal allergies

Full thickness

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?

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 clients discharge teaching?

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

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?

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

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?

Urine output of 20 mL/hr

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?

Wash your hands on entering the clients room.

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.)

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

A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond?

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

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?

Gather appropriate equipment and prepare for an emergency airway.

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?

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?

Keep the water temperature constant when showering the client.

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?

Place the client in an upright position.

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?

Serum potassium: 6.5 mEq/L

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?

Sometimes I wake up at night and smoke.

A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond?

When all of his burn wounds have closed.