Nokea
The nurse is caring for a client who sustained an electrical burn. Which priority action should the nurse take?
- A. Obtain an electrocardiogram (ECG)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Perform wound care
- D. Initiate supplemental oxygen
Correct Answer: A
Rationale: Electrical burns can cause cardiac dysrhythmias, so obtaining an ECG is the priority to assess heart rhythm.
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A nurse is taking care of a client with severe burns. Which of the following is the best intervention to prevent shock in this client?
- A. Administer dopamine as ordered
- B. Apply medical anti-shock trousers
- C. Infuse IV fluids as indicated
- D. Infuse fresh frozen plasma
Correct Answer: C
Rationale: Infusing IV fluids is the best intervention to prevent hypovolemic shock in burn patients by restoring circulating volume lost due to fluid shifts from severe burns.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 4 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Click to specify the interventions the nurse anticipates incorporating into the client's care plan
- A. Insertion of indwelling urinary catheter
- B. Irrigate wounds with cool saline solution
- C. Implement fluid restrictions
- D. Remove any jewelry from affected extremity
- E. Administer tetanus prophylaxis (Tdap)
Correct Answer: A, D, E
Rationale: Inserting a urinary catheter monitors fluid resuscitation, removing jewelry prevents constriction, and tetanus prophylaxis prevents infection. Cool saline is avoided as it can cause hypothermia, and fluid restrictions are inappropriate.
The wound care nurse is caring for a client at the outpatient clinic
Item 1 of 1
Nurses' Notes
Medical History
1300 - Client presents to the clinic on a referral from the primary healthcare provider for a wound to the right ankle area. The injury developed three months ago and has worsened despite topical treatment. On assessment, the wound is 5 cm x 4 cm and is shallow. The wound bed is pink with some granulation tissue; scant sanguineous drainage. Wound edges are uneven. Client reports pain only when dressing changes are performed, and the pain is rated as 5 on a scale of 0 (no pain) to 10 (severe pain). The surrounding skin on the affected foot is dry, darkened, and flaky. Capillary refill < 3 seconds. Peripheral pedal pulse 2+ on the affected foot. 3+ Ankle edema was noted in both lower extremities. The client denies leg pain during ambulation but endorses ankle swelling during the day while walking, and the only relieving factor is the application of a compression hose to both legs. The client reports applying a hot compress to the extremity but states after 2-3 applications, it worsened and became painful.
For each assessment finding below, click to specify if the finding is consistent with an arterial, venous, or diabetic ulcer. Each finding may support more than one (1) disease process.
- A. swelling in affected extremity
- B. pedal peripheral pulse 2+
- C. swelling relieved with compression hose
- D. denies leg pain during ambulation
- E. shallow wound bed
- F. medical history of hypertension and diabetes mellitus
- G. worsened with hot compress
Correct Answer: A: B, D, E, F; V: A, C, E; D: E, F, G
Rationale: Arterial ulcers: normal pulse, no leg pain, shallow wounds, and hypertension/diabetes history. Venous ulcers: swelling, compression relief, shallow wounds. Diabetic ulcers: shallow wounds, diabetes history, worsened with heat.
A nurse is assigned to care for a client who reportedly has no special skincare needs. However, upon assessment, the nurse observes reddened areas over bony prominences. What action should the nurse take?
- A. Document the finding and continue with routine care
- B. Apply a topical antibiotic ointment to the affected areas
- C. Conduct and document an emergency assessment
- D. Perform and document a focused assessment of skin integrity
Correct Answer: D
Rationale: Reddened areas over bony prominences suggest early pressure ulcers, requiring a focused skin integrity assessment to guide interventions.
The nurse plans to take which priority action?
- A. Assess the client's respiratory status
- B. Prepare an infusion of lactated ringers
- C. Insert an indwelling urinary catheter
- D. Obtain an accurate weight
Correct Answer: A
Rationale: Respiratory status is the priority due to the risk of airway compromise from burns to the torso and back.