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A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?
- A. I will allow my spouse to change my dressings.
- B. I want to have surgical reconstruction.
- C. I will bathe and dress before breakfast.
- D. I have secured the pressure dressings as ordered.
Correct Answer: C
Rationale: Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image.
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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 burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?
- A. Increase the clients oxygen and obtain blood gases.
- B. Draw blood for a carboxyhemoglobin level.
- C. Increase the clients intravenous fluid rate.
- D. Perform a thorough Mini-Mental State Examination.
Correct Answer: B
Rationale: Disorientation and headache are consistent with carbon monoxide poisoning, common in house fire victims. Drawing a carboxyhemoglobin level is the priority to confirm and guide treatment.
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 cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
- A. Assess the level of consciousness and pupillary reactions.
- B. Ascertain the time food or liquid was last consumed.
- C. Auscultate breath sounds over the trachea and bronchi.
- D. Measure abdominal breath sounds and auscultate bowel sounds.
Correct Answer: C
Rationale: Drooling and difficulty swallowing indicate a potential airway obstruction due to inhalation injury. Auscultating breath sounds over the trachea and bronchi is critical to assess for airway patency, which takes priority.
A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.)
- A. Administer analgesics.
- B. Prevent wound infections.
- C. Provide fluid replacement.
- D. Decrease core temperature.
- E. Initiate physical therapy.
Correct Answer: A,B,C
Rationale: During the resuscitation phase, priorities include administering analgesics for pain management, preventing wound infections, and providing fluid replacement to support circulation and organ perfusion.