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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.
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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.
A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.)
- A. Provide at least 5000 kcal/day.
- B. Start an oral diet on the first day.
- C. Administer a diet high in protein.
- D. Collaborate with a registered dietitian.
- E. Offer frequent high-calorie snacks.
Correct Answer: A,C,D,E
Rationale: Burn patients require a high-calorie (at least 5000 kcal/day), high-protein diet, frequent snacks, and collaboration with a dietitian to meet nutritional needs. Starting an oral diet on the first day may not be feasible due to medical instability.
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.
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.
Based on the data provided, how should the nurse categorize this clients injuries?
- A. Partial-thickness deep
- B. Partial-thickness superficial
- C. Full thickness
- D. Superficial
Correct Answer: C
Rationale: The wounds are described as white and leather-like with no blisters and minimal pain, consistent with full-thickness burns.