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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.
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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 receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 ml/kg/h. Which prescription should the nurse question?
- A. Increase intravenous fluids by 100 ml/hr.
- B. Administer furosemide (Lasix) 40 mg IV push.
- C. Continue to monitor urine output hourly.
- D. Draw blood for serum electrolytes STAT.
Correct Answer: B
Rationale: Furosemide is inappropriate as it promotes fluid loss, which is contraindicated in a client with inadequate urine output (0.5 ml/kg/hr is the target). Increasing fluids, monitoring urine output, and checking electrolytes are appropriate actions.
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 is planning care for a client with burn injuries to prevent infection. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Ensure everyone entering the clients room performs hand hygiene.
- B. Monitor the clients wounds daily for signs of infection.
- C. Clean equipment with alcohol between uses with each client on the unit.
- D. Allow family members to only bring the client plants from the hospitals gift shop.
- E. Use aseptic technique and wear gloves when performing wound care.
Correct Answer: A,B,E
Rationale: Hand hygiene, daily wound monitoring, and aseptic technique with gloves are critical for infection prevention. Shared equipment and plants increase infection risk.
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.