NCLEX Tissue Integrity-Care of Patients with Burns

NCLEX Tissue Integrity-Care of Patients with Burns Leave the first rating Students also studied Terms in this set (36) Science MedicineNursing Save Tissue Integrity - Burns, NCLEX Burn...45 terms taylor_devaney3 Preview NCLEX Tissue Integrity - Burns Ques...45 terms zmiller636Preview NCLEX Style Practice Questions Bur...100 terms akrrissman84Preview Hemod 35 terms ang The nursing student is caring for the client with open wound burns. Which nursing interventions will the nursing student provide for this client? Select all that apply.

• Provides cushions and rugs for comfort
• Performs frequent handwashing
• Places plants in the client's room
• Performs gloved dressing changes
• Uses disposable dishes
• Performs frequent handwashing
• Performs gloved dressing changes
• Uses disposable dishes

What is the best method to prevent autocontamination for the client with burns?

• Change gloves when handling wounds on different areas of the body.

Gloves should be changed when wounds on different areas of the body are handled and between handling old and new dressings Which strategies will the nurse include when teaching the college student about fire prevention in the dormitory room?Do not smoke in bed.Smoking in bed increases the risk for fire because the person could fall asleep.When teaching fire safety to parents at a school function, the school nurse offers advice about the placement of smoke and carbon monoxide detectors with which statement?"Every bedroom should have a separate smoke detector." The number of detectors needed depends on the size of the home.Recommendations are that each bedroom should have a separate smoke detector, at least one detector should be placed in the hallway of each floor of the house, and at least one detector is needed for the kitchen, stairway, and home entrance.The nurse is caring for the client with burns to the face.Which statement by the client requires further evaluation by the nurse?"I don't know what I will do when people stare at me." This statement indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques.

The client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client?Encouraging participation in wound care Encouraging participation in wound care will offer the client some sense of control.The nurse is caring for the client with burns. Which question will the nurse ask the client and family to assess their coping strategies?"How have you handled similar situations before?" This question assesses whether the client's and the family's coping strategies may be effective.The client who was the sole survivor in a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse?"Tell me more." This response encourages therapeutic grieving.Several clients have been brought to the emergency department (ED) after an office building fire. Which client is at greatest risk for inhalation injury?

• Middle-aged adult who is frantically explaining to the

nurse what happened

• Young adult who suffered burn injuries in a closed

space

• Adult with burns to the extremities
• Older adult with thick, tan-colored sputum
• Young adult who suffered burn injuries in a closed space

The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke.The newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations?Painful red and white blisters Painful red and white blisters accompany a deep partial-thickness burn.The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What will the nurse do first?Titrate fluid replacement.The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids).The client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours?Fluid resuscitation The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury.The nurse is evaluating the effectiveness of fluid resuscitation for the client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement?Urine output, 40 mL/hr Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL or 0.5 mL/kg/hr.Which assessment will the nurse prioritize for the client in the acute phase of burn injury?Signs of infection The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery.The client is in the acute phase of burn injury. In which situation will the nurse decide to coordinate with the dietitian?Planning additions to the standard nutritional pattern Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance.

Which clinical manifestation is indicative of wound healing for the client in the acute phase of burn injury?Scar tissue formation Indicators of wound healing include the presence of granulation, re- epithelization, and scar tissue formation.The client is in the resuscitation phase of burn injury.Which route will the nurse use to administer pain medication to the client?Intravenous During the resuscitation postburn phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.Which factors indicate that the client's burn wounds are becoming infected? Select all that apply.

• Dry, crusty granulation tissue
• Elevated blood pressure
• Hypoglycemia
• Swelling of the skin around the wound
• Tachycardia
• Tachycardia
• Swelling of the skin around the wound
• Dry, crusty granulation tissue

Hypotension is a systemic sign of infection.To position the client's burned upper extremities appropriately, how will the nurse position the client's elbow?In a neutral position The neutral position is the correct placement of the elbow to prevent contracture development.In assessing the client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate?Reduced self-image In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected.A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission.What is the nurse's best response to the client's family member?"Burn wound conditions promote the growth of Clostridium tetani." Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid, 0.5 mL given IM, enhances acquired immunity to C. tetani. This agent is routinely given when the client is admitted to the hospital.The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds.Which best describes the goal of topical antimicrobials?Reduction of bacterial growth in the wound and prevention of systemic sepsis Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds.The nurse is caring for a burn client who is receiving topical gentamicin sulfate (Garamycin). What laboratory value will the nurse plan to monitor?Serum and urine creatinine Topical gentamicin may have nephrotoxic effects, and the nurse should monitor serum and urine creatinine clearance before and during treatment.

When delegating care for clients on the burn unit, which client will the charge nurse assign to an RN who has floated to the burn unit from the pediatric unit?

• Burn unit client who is being discharged after 6 weeks

and needs teaching about wound care

• Recently admitted client with a high-voltage electrical

burn

• A client who has a 25% total body surface area (TBSA)

burn injury, for whom daily wound débridement has been prescribed

• Client receiving IV lactated Ringer's solution at 100

mL/hr

• Client receiving IV lactated Ringer's solution at 100 mL/hr

An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath.The nurse on a burn unit has just received change-of-shift report about these clients. Which client will the nurse assess first?

• Adult client admitted a week ago with deep partial-

thickness burns over 35% of the body who is reporting pain

• Firefighter with smoke inhalation and facial burns who

has just arrived on the unit and whispers, "I can't catch my breath!"

• An electrician who suffered external burn injuries a

month ago and is asking the nurse to contact the health care provider immediately about discharge plans

• Older adult client admitted yesterday with partial- and

full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

• Firefighter with smoke inhalation and facial burns who has just arrived on the

unit and whispers, "I can't catch my breath!" Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The client with difficulty breathing needs immediate assessment and intervention.A client with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit.The nurse plans to carry out which physician request first?

• Give oxygen per non-rebreather mask at 100% FiO2.
• Infuse lactated Ringer's solution at 150 mL/hr.
• Give morphine sulfate 4 to 10 mg IV for pain control.
• Insert a 14 Fr retention catheter.
• Give oxygen per non-rebreather mask at 100% FiO2.

Facial burns are frequently associated with upper airway inflammation.Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level.Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area will be of greatest concern to the nurse?

• Bowel sounds are absent.
• The pulse oximetry level is 91%.
• The serum potassium level is 8.1 mEq/L.
• Urine output since admission is 370 mL.
• The serum potassium level is 8.1 mEq/L.

An elevated serum potassium level can cause cardiac arrest.The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication?Furosemide (Lasix) Furosemide, a diuretic, generally is not given to improve urine output for burn clients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs.