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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.
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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.
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 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.
An emergency room nurse cares for a client admitted with a 50% burn injury at 1:00 AM this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number) ml/hr.
- A. 1500 ml/hr
- B. 1000 ml/hr
- C. 2000 ml/hr
- D. 1200 ml/hr
Correct Answer: A
Rationale: The Parkland formula (4 ml/kg/% burn) yields 18,000 ml for a 90-kg client with a 50% burn. Half (9000 ml) should be infused in the first 8 hours. Since infusion starts at noon (11 hours post-burn), 9000 ml must be given over 6 hours, resulting in 1500 ml/hr.
A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain?
- A. Administer the prescribed intravenous morphine sulfate.
- B. Apply ice to skin around the burn wound for 20 minutes.
- C. Administer prescribed intramuscular ketorolac (Toradol).
- D. Decrease tactile stimulation near the burn injuries.
Correct Answer: A
Rationale: Intravenous morphine sulfate is appropriate for pain management in burn injuries due to absorption issues with intramuscular routes and the need for rapid pain relief.