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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.
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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.
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.
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.
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.
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.