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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.
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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.
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.
A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: C
Rationale: According to the rule of nines, the back (posterior trunk) accounts for 18% and one arm accounts for 9%, totaling 27% of the body surface area.
A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.)
- A. Slower healing time increased risk for loss of function from contracture formation
- B. Reduced inflammatory response Deep partial-thickness wound with minimal exposure
- C. Reduced thoracic compliance Increased risk for atelectasis
- D. High incidence of cardiac impairments Increased risk for acute kidney injury
- E. Thinner skin May not exhibit a fever when infection is present
Correct Answer: A,C,D
Rationale: Slower healing increases contracture risk, reduced thoracic compliance increases atelectasis risk, and cardiac impairments increase acute kidney injury risk in older burn patients.
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.