Nokea
An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/ml. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) drops/min
- A. 333 drops/min
- B. 300 drops/min
- C. 350 drops/min
- D. 320 drops/min
Correct Answer: A
Rationale: 1000 ml over 90 minutes with a drip factor of 30 drops/ml: (1000 ÷ 90) ? 30 = 333 drops/min.
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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 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.
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 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.
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.