Quiz 4: Burns

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?

Slow the IV rate and notify the healthcare provider.

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?

4200 mL

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?

60 minutes before the dressing change

Which action should be the nurse's first priority for a client with major burns?

Assessing airway patency

A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? Select all that apply

Burn odor Leathery skin Cardiac arrest

What would be the priority nursing intervention in a client with electric burns?

Checking the airway, breathing and circulation

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?

Electrical burn

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

Hypothermia

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.

Leave the adherent clothing in place. Wrap the client in a dry clean sheet. Remove as much burned clothing as possible.

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?

Maintain blood volume

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?

Removing the clothes of the client

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.

Tar

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?

Cool, moist towels

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?

Urinalysis and urine culture and sensitivity

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.

Using a low heat setting when cooking

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 check pulses distal to burns."

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

Client C

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?

First-degree 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?

Gentamicin sulfate

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?

"A localized skin reaction usually occurs."

The nurse is caring for a client who survived a severe burn injury. Which action should the nurse perform immediately based on priority?

Assessing airway patency

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?

Crackles in the lungs

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?

Slowing of a previously rapid pulse rate

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?

Client with visible thrombosed vessels