Care of Patients with Burns

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Med Surg: Chapter 23

26 terms mmyoung00Preview Ch. 22 A 13 terms Me 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?

• Administer the prescribed tetanus toxoid vaccine.
• Assess the clients wounds for signs of infection.
• Encourage the client to breathe deeply every hour.
• Wash your hands on entering the clients room.

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

• Use a disposable blood pressure cuff to avoid sharing

with other clients.

• Change gloves between wound care on different parts

of the clients body.

• Use the closed method of burn wound management

for all wound care.

• Advocate for proper and consistent handwashing by

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

• I get my chimney swept every other year.
• My hot water heater is set at 120 degrees.
• Sometimes I wake up at night and smoke.
• I use a space heater when it gets below zero.

C

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

• 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.

• You shouldnt start worrying about your appearance

right now.C 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 allow my spouse to change my dressings.
• I want to have surgical reconstruction.
• I will bathe and dress before breakfast.
• I have secured the pressure dressings as ordered.

C 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.
• I will go back to work immediately.
• I will not feel anger about my situation.
• Once I get home, things will be normal.

A 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.
• Provide small quantities of ice chips and sips of water.
• Request a prescription for an antitussive medication.
• Ask the respiratory therapist to provide humidified air.

A 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?

• Tagamet stimulates intestinal movement so you can eat

more.

• It improves fluid retention, which helps prevent

hypovolemic shock.

• It helps prevent stomach ulcers, which are common

after burns.

• Tagamet protects the kidney from damage caused by

dehydration.C

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

• Assess the level of consciousness and pupillary

reactions.

• Ascertain the time food or liquid was last consumed.
• Auscultate breath sounds over the trachea and bronchi.
• Measure abdominal girth and auscultate bowel sounds.

C 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?

• Increase intravenous fluids by 100 mL/hr.
• Administer furosemide (Lasix) 40 mg IV push.
• Continue to monitor urine output hourly.
• Draw blood for serum electrolytes STAT.

B 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?

a. Arterial pH: 7.32

b. Hematocrit: 52%

c. Serum potassium: 6.5 mEq/L

d. Serum sodium: 131 mEq/L

C 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?

• Administer furosemide (Lasix).
• Perform chest physiotherapy.
• Document and reassess in an hour.
• Place the client in an upright position.

D 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 the antibiotic therapy is complete.
• As soon as his albumin levels return to normal.
• Once we complete the fluid resuscitation process.
• When all of his burn wounds have closed.

D 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
• Red blood cells
• Sodium
• Magnesium

A

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.

• Apply ice to skin around the burn wound for 20

minutes.

• Administer prescribed intramuscular ketorolac

(Toradol).

• Decrease tactile stimulation near the burn injuries.

A 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?

• Increase the clients oxygen and obtain blood gases.
• Draw blood for a carboxyhemoglobin level.
• Increase the clients intravenous fluid rate.
• Perform a thorough Mini-Mental State Examination.

B A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching?

• You should change the batteries in your smoke

detector once a year.

• Join a program that assists burn clients to reintegration

into the community.

• I will demonstrate how to change your wound dressing

for you and your family.

• Let me tell you about the many options available to

you for reconstructive surgery.C 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?

• Document the findings and reassess in 1 hour.
• Loosen any constrictive dressings on the chest.
• Raise the head of the bed to a semi-Fowlers position.
• Gather appropriate equipment and prepare for an

emergency airway.D 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?

• 9%
• 18%
• 27%
• 36%

C