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The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury?
- A. It is normal to feel some depression.
- B. I will go back to work immediately.
- C. I will not feel anger about my situation.
- D. Once I get home, things will be normal.
Correct Answer: A
Rationale: During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems.
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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.
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.
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.
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 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.