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A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond?
- A. Tagamet stimulates intestinal movement so you can eat more.
- B. It improves fluid retention, which helps prevent hypovolemic shock.
- C. It helps prevent stomach ulcers, which are common after burns.
- D. Tagamet protects the kidney from damage caused by dehydration.
Correct Answer: C
Rationale: Ulcerative gastrointestinal disease (Curling's ulcer) may develop within 24 hours after a severe burn due to increased hydrochloric acid production and a decreased mucosal barrier. Cimetidine is a histamine blocker that inhibits the production and release of hydrochloric acid.
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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.
Based on the data provided, how should the nurse categorize this clients injuries?
- A. Partial-thickness deep
- B. Partial-thickness superficial
- C. Full thickness
- D. Superficial
Correct Answer: C
Rationale: The wounds are described as white and leather-like with no blisters and minimal pain, consistent with full-thickness burns.
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 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.
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.