CARE OF PATIENTS WITH BURNS

Questions: Care of Patient with Burns 1.ID: 293385700 The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN? Administer the prescribed tetanus toxoid vaccine. Assess wounds for signs of infection. Have the client cough and breathe deeply. Wash hands on entering the client’s room. Correct 2.ID: 293384888 When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? Avoid sharing equipment such as blood pressure cuffs between clients. Change gloves between wound care on different parts of the client’s body. Correct Use the closed method of burn wound management for all wound care. Use proper and consistent handwashing by all members of the staff. 3.ID: 293384898 The nurse is teaching burn prevention to a community group. Which information shared by a member of the group causes the nurse the greatest concern? “I get my chimneys swept every other year.” “My hot water heater is set at about 120 degrees.” “Sometimes I wake up at night and smoke.” Correct “I use a space heater when it gets below zero.” 4.ID: 293384896 The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan? Have an escape route everyone knows about. Keep a smoke detector in each bedroom. Correct Use space heaters instead of gas heaters. Use carbon monoxide detectors in the garage. 5.ID: 293385708 A client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide? “With reconstructive surgery, you can look the same.” “We can remove the scars with the use of a pressure dressing.” “You will not look exactly the same but cosmetic surgery will help.” Correct “You shouldn’t start worrying about your appearance right now.” 6.ID: 293385726 The nurse has provided instruction on the facial pressure garment to a client with facial burns. Which statement indicates that the client understands these instructions? “My scars should be less severe with the use of this mask.” Correct “The mask will help protect my skin from sun damage.” “This treatment will help prevent infection.” “Using the mask will keep scars from being permanent.” 7.ID: 293385728 Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance? Allowing family members to change the dressings Discussing future surgical reconstruction Performing morning care independently Correct Wearing the pressure dressings as ordered 8.ID: 293385746 Which statement best exemplifies a client’s understanding of rehabilitation after a full-thickness burn injury? “I am fully recovered when all the wounds are closed.” “I will eventually be able to perform all my former activities.” “My goal is to achieve the highest level of functioning that I can.” Correct “Full recovery from a major burn injury never occurs.” 9.ID: 293385740 Which finding indicates to the nurse that a client understands the psychosocial impact of a severe burn injury? “It is normal to feel some depression.” Correct “I will go back to work immediately.” “I will not feel anger about my situation.” “Once I get home, things will be normal.” 10.ID: 293385750 A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority? Apply oxygen and continuous pulse oximetry. Correct Allow the client to suck on small quantities of ice chips. Request an antitussive medication from the physician. Have the respiratory therapist provide humidified room air. 11.ID: 293385702 A client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding is present, and the client describes just a “small amount of pain.” How does the nurse categorize this injury? Partial thickness deep Partial thickness superficial Full thickness Correct Superficial 12.ID: 293384894 A client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How does the nurse categorize this injury? Full thickness Partial thickness superficial Correct Partial thickness deep Superficial 13.ID: 293385714 A client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse’s best response? “Tagamet will stimulate intestinal movement so you can eat more.” “Tagamet can help prevent hypovolemic shock, which can be fatal.” “This will help prevent stomach ulcers, which are common after burns.” Correct “This drug will help prevent kidney damage caused by dehydration.” 14.ID: 293385752 A client who is burned is drooling and is having difficulty swallowing. Which action does the nurse take first? Assess level of consciousness and pupillary reactions. Ascertain the time food or liquid was last consumed. Auscultate breath sounds over the trachea and main stem bronchi. Correct Measure abdominal girth and auscultate bowel sounds. 15.ID: 293385748 On assessment, the nurse notes that a client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse’s next action? Document the findings and reassess in 1 hour. Loosen any constrictive dressings on the chest. Raise the head of the bed to a semi-Fowler’s position. Gather appropriate equipment and prepare for intubation. Correct 16.ID: 293385716 A client who is receiving fluid resuscitation per the Parkland formula after a serious burn continues to have urine output ranging from 0.2 to 0.25 mL/kg/hour. After the health care provider checks the client, which order does the nurse question? Increase IV fluids by 100 mL/hr. Administer furosemide (Lasix) 40 mg IV push. Correct Continue to monitor urine output hourly. Draw blood for serum electrolytes stat. 17.ID: 293385760 A client is 24 hours post burn and has the following laboratory results. Which result does the nurse report to the health care provider immediately? Arterial pH, 7.32 Hematocrit, 52% Serum potassium,7.5 mEq/L Correct Serum sodium, 131 mEq/L 18.ID: 293384892 Ten hours after a client with 50% burns is admitted, her blood glucose level is 152 mg/dL. What action by the nurse is most appropriate? Document the finding. Correct Obtain a family history for diabetes. Repeat the glucose measurement. Stop IV fluids containing dextrose. 19.ID: 293384890 A client who was burned has crackles in both lung bases and a respiratory rate of 40 breaths/min and is coughing up blood-tinged sputum. Which action by the nurse takes priority? Administer digoxin. Perform chest physiotherapy. Document and reassess in an hour. Place the client in an upright position. Correct 20.ID: 293385704 A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; and respiratory rate, 25 breaths/min. He is pale, and it is difficult to find pedal pulses. Which action does the nurse take first? Begin intravenous fluid resuscitation. Correct Check pulses with a Doppler device. Obtain a complete blood count (CBC). Obtain an electrocardiogram (ECG). 21.ID: 293385706 A client is brought to the emergency department by an emergency medical services (EMS) squad after being burned with unknown chemicals. The client’s body is covered with a white, powdery substance, and the client cries out, “Get this stuff off me! It’s burning me!” Which action by the nurse is most appropriate? Have the client take a shower, and bag all clothing. Brush the substance off the client and remove clothes. Correct Call poison control to try to identify the chemical. Start an IV line and prepare to administer analgesics. 22.ID: 293385710 A client suffered a 45% total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds were absent in all four abdominal quadrants. Which is the nurse’s best action? Administer a laxative. Document the finding. Prepare to insert a nasogastric (NG) tube. Correct Reposition the client on the right side. 23.ID: 293385732 A client has experienced an electrical injury of the lower extremities. Which priority assessment data should be obtained from this client? Range of motion in all extremities Heart rate, rhythm, and electrocardiogram (ECG) Correct