Nokea
A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
- A. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg
- B. Urine output of 20 ml/hr
- C. Productive cough with white pulmonary secretions
- D. Core temperature of 100.6°F (38°C)
Correct Answer: B
Rationale: A urine output of 20 ml/hr indicates inadequate fluid resuscitation, which can lead to hypoperfusion and organ damage, a critical complication in burn injuries.
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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?
- A. Administer the prescribed tetanus toxoid vaccine.
- B. Assess the clients wounds for signs of infection.
- C. Encourage the client to breathe deeply every hour.
- D. Wash your hands on entering the clients room.
Correct Answer: D
Rationale: Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.
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?
- A. Tagamet stimulates intestinal movement so you can eat more.
- B. It improves fluid retention, which helps prevent hypovolemic shock.
- C. It helps prevent stomach ulcers, which are common after burns.
- D. Tagamet protects the kidney from damage caused by dehydration.
Correct Answer: C
Rationale: Ulcerative gastrointestinal disease (Curling's ulcer) may develop within 24 hours after a severe burn due to increased hydrochloric acid production and a decreased mucosal barrier. Cimetidine is a histamine blocker that inhibits the production and release of hydrochloric acid.
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?
- A. Administer furosemide (Lasix).
- B. Perform chest physiotherapy.
- C. Document and reassess in an hour.
- D. Place the client in an upright position.
Correct Answer: D
Rationale: These symptoms suggest pulmonary edema, possibly from fluid resuscitation. Placing the client in an upright position can relieve lung congestion immediately while other measures are planned.
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.
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?
- A. Apply oxygen and continuous pulse oximetry.
- B. Provide small quantities of ice chips and sips of water.
- C. Request a prescription for an antitussive medication.
- D. Ask the respiratory therapist to provide humidified air.
Correct Answer: A
Rationale: Brassy cough and wheezing are signs of inhalation injury. The first action by the nurse should be to apply oxygen and monitor with continuous pulse oximetry to ensure adequate oxygenation.