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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.
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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.
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 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.
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 delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity?
- A. Keep the water temperature constant when showering the client.
- B. Assess the wound beds during the hydrotherapy treatment.
- C. Apply a topical enzyme agent after bathing the client.
- D. Use sterile saline to irrigate and clean the clients wounds.
Correct Answer: A
Rationale: Hydrotherapy involves showering the client on a special table with a constant water temperature to ensure comfort and safety. Wound assessment and topical treatments are nursing responsibilities.