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Based on the documented data, which action should the nurse take next?
- A. Assess the clients skin for signs of adequate perfusion.
- B. Calculate intake and output ratio for the last 24 hours.
- C. Prepare to obtain blood and wound cultures.
- D. Place the client in an isolation room.
Correct Answer: C
Rationale: The burn wound shows signs of local infection in an older client, who may not exhibit typical signs of infection. Obtaining blood and wound cultures is the priority to confirm and treat infection.
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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.
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 severe inhalation injuries who is being monitored in the intensive care unit. Which finding indicates to the nurse that the client is experiencing airway obstruction?
- A. No wheezing or breath sounds
- B. Low oxygen saturation levels
- C. Restlessness and confusion
- D. Elevated respiratory rate
Correct Answer: D
Rationale: Clients with severe inhalation injuries may develop progressive airway obstruction, leading to a loss of wheezing and breath sounds, indicating a critical need for an emergency airway.
A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?
- A. Increase the clients oxygen and obtain blood gases.
- B. Draw blood for a carboxyhemoglobin level.
- C. Increase the clients intravenous fluid rate.
- D. Perform a thorough Mini-Mental State Examination.
Correct Answer: B
Rationale: Disorientation and headache are consistent with carbon monoxide poisoning, common in house fire victims. Drawing a carboxyhemoglobin level is the priority to confirm and guide treatment.
An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first?
- A. Apply oxygen and continuous pulse oximetry.
- B. Provide small quantities of ice chips and sips of water.
- C. Request a prescription for an antitussive medication.
- D. Ask the respiratory therapist to provide humidified air.
Correct Answer: A
Rationale: Brassy cough and wheezing are signs of inhalation injury. The first action by the nurse should be to apply oxygen and monitor with continuous pulse oximetry to ensure adequate oxygenation.