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A nurse cares for a client with severe inhalation injuries who is being monitored in the intensive care unit. Which finding indicates to the nurse that the client is experiencing airway obstruction?
- A. No wheezing or breath sounds
- B. Low oxygen saturation levels
- C. Restlessness and confusion
- D. Elevated respiratory rate
Correct Answer: D
Rationale: Clients with severe inhalation injuries may develop progressive airway obstruction, leading to a loss of wheezing and breath sounds, indicating a critical need for an emergency airway.
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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.
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.
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 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.
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.