Nokea
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.
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The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?
- A. I get my chimney sweep every other year.
- B. My hot water heater is set at 120 degrees.
- C. Sometimes I wake up at night and smoke.
- D. I use a space heater when it gets below zero.
Correct Answer: C
Rationale: House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes, as this could involve smoking in bed, which poses a significant fire risk if the person falls back asleep with a lighted cigarette.
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 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.
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.
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.