Nokea
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.
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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.
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 plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.)
- A. Provide at least 5000 kcal/day.
- B. Start an oral diet on the first day.
- C. Administer a diet high in protein.
- D. Collaborate with a registered dietitian.
- E. Offer frequent high-calorie snacks.
Correct Answer: A,C,D,E
Rationale: Burn patients require a high-calorie (at least 5000 kcal/day), high-protein diet, frequent snacks, and collaboration with a dietitian to meet nutritional needs. Starting an oral diet on the first day may not be feasible due to medical instability.
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.
The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury?
- A. It is normal to feel some depression.
- B. I will go back to work immediately.
- C. I will not feel anger about my situation.
- D. Once I get home, things will be normal.
Correct Answer: A
Rationale: During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems.