Nokea
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.
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A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)
- A. Music as a distraction
- B. Tactile stimulation
- C. Massage to injury sites
- D. Cold compresses
- E. Increasing client control
Correct Answer: A,B,E
Rationale: Nonpharmacologic measures like music therapy, tactile stimulation, and increasing client control can help manage anxiety and pain. Massage to injury sites and cold compresses are not appropriate for burn injuries.
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 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.
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.
A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond?
- A. Tagamet stimulates intestinal movement so you can eat more.
- B. It improves fluid retention, which helps prevent hypovolemic shock.
- C. It helps prevent stomach ulcers, which are common after burns.
- D. Tagamet protects the kidney from damage caused by dehydration.
Correct Answer: C
Rationale: Ulcerative gastrointestinal disease (Curling's ulcer) may develop within 24 hours after a severe burn due to increased hydrochloric acid production and a decreased mucosal barrier. Cimetidine is a histamine blocker that inhibits the production and release of hydrochloric acid.