Nokea
A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching?
- A. You should change the batteries in your smoke detector once a year.
- B. Join a program that assists burn clients to reintegration into the community.
- C. I will demonstrate how to change your wound dressing for you and your family.
- D. Let me tell you about the many options available to you for reconstructive surgery.
Correct Answer: C
Rationale: Teaching clients and family members to perform dressing changes is critical for ongoing wound care management post-discharge.
You may also like to solve these questions
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 assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
- A. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg
- B. Urine output of 20 ml/hr
- C. Productive cough with white pulmonary secretions
- D. Core temperature of 100.6°F (38°C)
Correct Answer: B
Rationale: A urine output of 20 ml/hr indicates inadequate fluid resuscitation, which can lead to hypoperfusion and organ damage, a critical complication in burn injuries.
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 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.
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.