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A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately?
- A. Arterial pH: 7.32
- B. Hematocrit: 52%
- C. Serum potassium: 6.5 mEq/L
- D. Serum sodium: 131 mEq/L
Correct Answer: C
Rationale: A serum potassium level of 6.5 mEq/L indicates hyperkalemia, which poses a high risk for severe cardiac dysrhythmias and requires immediate reporting.
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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.
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.
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 is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?
- A. Use a disposable blood pressure cuff to avoid sharing with other clients.
- B. Change gloves between wound care on different parts of the clients body.
- C. Use the closed method of burn wound management for all wound care.
- D. Advocate for proper and consistent handwashing by all members of the staff.
Correct Answer: B
Rationale: Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the clients body can prevent autocontamination.
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.