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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.
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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.
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 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 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 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.