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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.
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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 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 cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond?
- A. When the antibiotic therapy is complete.
- B. As soon as his albumin levels return to normal.
- C. Once we complete the fluid resuscitation process.
- D. When all of his burn wounds have closed.
Correct Answer: D
Rationale: Intact skin is a major barrier to infection. The client remains at high risk for infection as long as any area of skin is open.
The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client?
- A. Administer the prescribed tetanus toxoid vaccine.
- B. Assess the clients wounds for signs of infection.
- C. Encourage the client to breathe deeply every hour.
- D. Wash your hands on entering the clients room.
Correct Answer: D
Rationale: Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.
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.