Nokea
A nurse administers topical Pandora gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy?
- A. Creatinine
- B. Red blood cells
- C. Sodium
- D. Magnesium
Correct Answer: A
Rationale: Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Creatinine levels should be monitored to assess kidney function.
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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?
- A. It is normal to feel some depression.
- B. I will go back to work immediately.
- C. I will not feel anger about my situation.
- D. Once I get home, things will be normal.
Correct Answer: A
Rationale: During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems.
An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/ml. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) drops/min
- A. 333 drops/min
- B. 300 drops/min
- C. 350 drops/min
- D. 320 drops/min
Correct Answer: A
Rationale: 1000 ml over 90 minutes with a drip factor of 30 drops/ml: (1000 ÷ 90) ? 30 = 333 drops/min.
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?
- A. When the antibiotic therapy is complete.
- B. As soon as his albumin levels return to normal.
- C. Once we complete the fluid resuscitation process.
- D. When all of his burn wounds have closed.
Correct Answer: D
Rationale: Intact skin is a major barrier to infection. The client remains at high risk for infection as long as any area of skin is open.
A nurse cares for a client with severe inhalation injuries who is being monitored in the intensive care unit. Which finding indicates to the nurse that the client is experiencing airway obstruction?
- A. No wheezing or breath sounds
- B. Low oxygen saturation levels
- C. Restlessness and confusion
- D. Elevated respiratory rate
Correct Answer: D
Rationale: Clients with severe inhalation injuries may develop progressive airway obstruction, leading to a loss of wheezing and breath sounds, indicating a critical need for an emergency airway.
A nurse is planning care for a client with burn injuries to prevent infection. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Ensure everyone entering the clients room performs hand hygiene.
- B. Monitor the clients wounds daily for signs of infection.
- C. Clean equipment with alcohol between uses with each client on the unit.
- D. Allow family members to only bring the client plants from the hospitals gift shop.
- E. Use aseptic technique and wear gloves when performing wound care.
Correct Answer: A,B,E
Rationale: Hand hygiene, daily wound monitoring, and aseptic technique with gloves are critical for infection prevention. Shared equipment and plants increase infection risk.