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A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: C
Rationale: According to the rule of nines, the back (posterior trunk) accounts for 18% and one arm accounts for 9%, totaling 27% of the body surface area.
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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.
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.
A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?
- A. I will allow my spouse to change my dressings.
- B. I want to have surgical reconstruction.
- C. I will bathe and dress before breakfast.
- D. I have secured the pressure dressings as ordered.
Correct Answer: C
Rationale: Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image.
An emergency room nurse cares for a client admitted with a 50% burn injury at 1:00 AM this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number) ml/hr.
- A. 1500 ml/hr
- B. 1000 ml/hr
- C. 2000 ml/hr
- D. 1200 ml/hr
Correct Answer: A
Rationale: The Parkland formula (4 ml/kg/% burn) yields 18,000 ml for a 90-kg client with a 50% burn. Half (9000 ml) should be infused in the first 8 hours. Since infusion starts at noon (11 hours post-burn), 9000 ml must be given over 6 hours, resulting in 1500 ml/hr.
A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
- A. Assess the level of consciousness and pupillary reactions.
- B. Ascertain the time food or liquid was last consumed.
- C. Auscultate breath sounds over the trachea and bronchi.
- D. Measure abdominal breath sounds and auscultate bowel sounds.
Correct Answer: C
Rationale: Drooling and difficulty swallowing indicate a potential airway obstruction due to inhalation injury. Auscultating breath sounds over the trachea and bronchi is critical to assess for airway patency, which takes priority.