Nokea
A client who was severely burned goes to the Hubbard tank daily. Tanking sessions are limited to a half hour for which reason?
- A. A longer period of time is too tiring.
- B. Eschar becomes difficult to remove with longer soaking.
- C. Prolonged soaking causes electrolyte dilution.
- D. The water becomes too cool and may cause chilling.
Correct Answer: C
Rationale: Prolonged soaking in the Hubbard tank can lead to electrolyte dilution, risking imbalances in burn clients who are already prone to fluid and electrolyte shifts.
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What is the best advice the nurse can offer the nursing assistant?
- A. Rinse your latex gloves with running tap water before putting them on.
- B. Apply a petroleum ointment to both hands before putting on latex gloves.
- C. Don't wear gloves, but wash your hands vigorously with alcohol after client contact.
- D. Wear two pairs of vinyl gloves when there's a potential for contact with body fluids.
Correct Answer: D
Rationale: Vinyl gloves avoid latex exposure while maintaining protection.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply.
- A. Perform meticulous hand hygiene.
- B. Use sterile gloves for wound care.
- C. Wear gown and mask during procedures.
- D. Change central lines once a week.
- E. Administer antibiotics as prescribed.
Correct Answer: A,B,C,E
Rationale: Hand hygiene, sterile gloves, gown/mask, and antibiotics prevent infection in extensive burns. Weekly central line changes are not standard; daily assessment is preferred.
A 28-year-old man received severe burns of the chest, abdomen, back, legs, and hands when the house caught fire. In the emergency room, a nasogastric tube was inserted, and the client was ordered NPO. What is the primary reason for the nurse to keep this client NPO?
- A. To prevent the deadly complication of aspiration
- B. To make the client more comfortable
- C. To help prevent paralytic ileus
- D. To help prevent excessive fluid loss
Correct Answer: C
Rationale: Severe burns predispose clients to paralytic ileus due to stress and fluid shifts, so keeping the client NPO prevents complications until bowel function returns.
Which response by the nurse is best at this time?
- A. I'm sure you will look absolutely gorgeous.
- B. I didn't think you were unattractive before.
- C. Your face is swollen with bruises around the eyes.
- D. Your personality is more important than your looks.
Correct Answer: C
Rationale: An honest response about expected swelling prepares the client for recovery.
Which area of health teaching is essential when a female client is prescribed isotretinoin (Accutane)?
- A. Breast self-examination techniques
- B. Techniques for avoiding pregnancy
- C. Methods for predicting ovulation
- D. Information on preventing sexual transmission
Correct Answer: B
Rationale: Isotretinoin is teratogenic, requiring strict pregnancy prevention.