Burn
The primary healthcare provider instructs the nurse to monitor serum creatinine and blood urea nitrogen in a client who is on therapy for burn wounds. Which medication most likely has been prescribed to the client?
1 Nitrofurantoin 2 Mafenide acetate 3 Silver sulfadiazine Correct4 Gentamicin sulfate
The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication?
15 minutes before the dressing change Correct2 60 minutes before the dressing change 3 Along with a stool softener each time it is administered 4 Only if the client rates pain between 8 and 10 on the pain scale
A client has burn injuries sustained from an electrical current. What are the interventions to follow until the client is transferred to the primary healthcare center? Select all that apply.
Cover the burns with ice. Correct2 Leave the adherent clothing in place. Correct3 Wrap the client in a dry clean sheet. Correct4 Remove as much burned clothing as possible. 5 Immerse the burned body part in cool water.
A registered nurse teaches a new orienting nurse about interventions to be followed for a client with burns due to inhalation injury. Which statement made by the new orienting nurse indicates the new nurse needs more orientation?
"I should administer intravenous analgesia." Correct2 "I should check pulses distal to burns." 3 "I should prepare for an endotracheal intubation." 4 "I should anticipate the need for fiberoptic bronchoscopy.
The nurse is caring for four clients who have survived burn injuries from a chemical plant explosion. Which client requires immediate surgical intervention based on priority?
1 Client with erythema 2 Client with fluid-filled vesicles 3 Client with mild to moderate edema Correct4 Client with visible thrombosed vessels
Which teaching points should the nurse include when educating the parents of a school-age client to decrease the risk for burn injury? Select all that apply.
1 Securing seat belts properly Correct2 Using a low heat setting when cooking 3 Recommending enrollment in swimming lessons Correct4 Instructing on the stop, drop, and roll technique Correct5 Making sure smoke detectors are installed in the home
A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? Select all that apply
1: Coughing Correct2 Burn odor 3:Smoky breath Correct4 Leathery skin Correct5 Cardiac arrest
A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn." What is the nurse's best response?
1 "Your skin will look like a blistering sunburn." Correct2 "A localized skin reaction usually occurs." 3 "A daily application of an emollient will prevent a burn." 4 "Your family must have had experience with radiation therapy."
A client who is recovering from deep partial-thickness burns develops chills, fever, flank pain, and malaise. The primary healthcare provider makes a tentative diagnosis of urinary tract infection. Which diagnostic tests should the nurse expect the primary healthcare provider to prescribe to confirm this diagnosis?
1 Cystoscopy and bilirubin level 2 Specific gravity and pH of the urine Correct3 Urinalysis and urine culture and sensitivity 4 Creatinine clearance and albumin/globulin (A/G) ratio
The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment?
1 Determining the level of mobility Correct2 Removing the clothes of the client 3 Placing the client in recumbent position 4 Cleaning the wounds with antiseptic solution
The nurse is caring for a client who survived a severe burn injury. Which action should the nurse perform immediately based on priority?
1 Obtaining vital signs Correct2 Assessing airway patency 3 Providing fluid replacement 4 Elevating the extremities if there is no fracture
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 Correct3 Maintain blood volume 4 Replace electrolytes lost
A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?
Correct1 Crackles in the lungs 2 Decreased heart rate 3 Decreased blood pressure 4 Cyanosi
A client was admitted with a burn injury caused by a quick heat flash. The nurse examined the skin and noticed erythema and mild swelling. What type of burn does the nurse suspect?
Correct1 First-degree burn 2 Third-degree burn 3 Fourth-degree burn 4 Second-degree burn
What would be the priority nursing intervention in a client with electric burns?
Gently removing the burned cloth 2 Wrapping the client in a dry clean sheet 3 Cooling the burns for no more than 10 min Correct4 Checking the airway, breathing and circulation
A client is rescued from a house fire and arrives at the emergency department 1 hour after the rescue. The client weighs 132 pounds (60 kilograms) and is burned over 35% of the body. The nurse expects that the amount of lactated Ringer solution that will be prescribed to be infused in the next 8 hours is what?
1 2100 mL Correct2 4200 mL 3 6300 mL 4 8400 mL
The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing
1 Bradypnea 2 Bradycardia 3 Hypotension Correct4 Hypothermia
A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained?
1 Flame burn 2 Chemical burn Correct3 Electrical burn 4 Radiation burn
The nurse is examining four different clients who present with thermal burns. Which client does the nurse diagnose as having second-degree burns? A: Waxy White, dark-brown apperance B: Redness, pain, minimal edema C: Moist blebs, blister, severe pain D: Dry, Leathery, eschar, absence of pain
1:Client A 2:Client B Correct3 Client C 4 Client D
Which action should be the nurse's first priority for a client with major burns?
Correct1 Assessing airway patency 2 Checking the client from head to toe 3 Administering oxygen as needed 4 Elevating the extremities if no fractures are noticed
A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure the nurse can instruct the person to apply before seeking healthcare?
Correct1 Cool, moist towels 2 Dry, sterile dressings 3 Analgesic sunburn spray 4 Vitamin A and D ointment
A client is admitted to the burn unit with partial-thickness burns over 30% of the body surface area. Twenty-four hours later, the client, who has an intravenous (IV) line of 5% dextrose in saline running, has tremors, twitching, and signs of disorientation. During the past hour the urinary output was 110 mL. What should the nurse do next?
Correct1 Slow the IV rate and notify the healthcare provider. 2 Slow the IV rate and check the last chest x-ray film. 3 Increase the IV rate and assess the arterial blood gases. 4 Increase the IV rate and request a prescription for calcium gluconate
A nurse is teaching a safety class about burns. Which examples will the nurse use to describe occupational hazards for burn injuries? Select all that apply.
Correct1 Tar Correct2 Power lines Correct3 Fertilizers 4 Radiators 5 Outdoor grills
The nurse is caring for a client with a 30% total body surface area burn. Which assessment finding indicates to the nurse that the client's fluid replacement is adequate?
1 Increasing hematocrit level 2 Urinary output of 15 to 20 mL/hr Correct3 Slowing of a previously rapid pulse rate 4 Central venous pressure progressing from 5 to 1 mm Hg