Nokea
The nurse is planning care for a newly burned client. What is the priority nursing observation to be made during the first 48 hours after the burn?
- A. Hourly blood pressure
- B. Assessment of skin color and capillary refill
- C. Hourly urine measurement
- D. Frequent assessment for pain
Correct Answer: C
Rationale: Hourly urine measurement is critical in the first 48 hours to monitor fluid resuscitation effectiveness and prevent hypovolemic shock.
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The nurse who documents the burn injury is accurate in identifying the full-thickness burns as having what appearance?
- A. White and leathery
- B. Pink and blistered
- C. Red and painful
- D. Mottled and wet
Correct Answer: A
Rationale: Full-thickness burns appear white, leathery, and painless due to nerve destruction.
The nurse is caring for the client with a burn injury. Which findings should prompt the nurse to notify the HCP because the client may be developing sepsis?
- A. Paco2 35 mm Hg and blood glucose level 250
- B. Bleeding from IV site and blood glucose level 55
- C. Temperature 103.2°F (39.6°C) and heart rate 120 bpm
- D. Respiratory rate 34 breaths/min and WBC 10,000/mm3
Correct Answer: C
Rationale: T 103.2°F (39.6°C) and HR 120 bpm may indicate that the client has sepsis. A Paco2 35 mm Hg is WNL. Hyperglycemia does occur in sepsis, but this alone is not sufficient. Abnormal clotting may occur with sepsis, but hypoglycemia does not. An RR of 34 breaths/min may indicate sepsis, but the WBC is WNL.
The nurse is assessing the client for possible scabies infestation. Which findings should the nurse expect?
- A. Serosanguineous drainage and fever
- B. Malaise and local edema
- C. Itching and papule-like rash
- D. Macule rash and blisters
Correct Answer: C
Rationale: The most common symptoms of a scabies infestation are itching and papule rash. Serosanguineous drainage and fever or malaise and edema occur with wound infections. Macule rash and blisters may occur with allergic reactions.
The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion?
- A. Instruct the clients to wear dark clothes when hunting.
- B. Use a sunscreen of at least SPF 30 when outside.
- C. Avoid dense undergrowth when in a wooded area.
- D. Do not use any type of insect repellant when deer hunting.
Correct Answer: C
Rationale: Avoiding dense undergrowth reduces tick exposure, preventing Lyme disease. Dark clothes attract ticks, sunscreen is irrelevant, and insect repellent is recommended.
The nurse is caring for clients with second- and third-degree burns. Which medication should the nurse plan to apply topically to treat bacterial and yeast infections?
- A. Bismuth subsalicylate
- B. Gold sodium thiomalate
- C. Silver sulfadiazine
- D. Arsenic trioxide
Correct Answer: C
Rationale: Silver sulfadiazine (Silvadene) is a topical anti-infective agent for prevention and treatment of wound infection in second- and third-degree burn clients. Bismuth subsalicylate (Kaopectate) is an antidiarrheal medication. Gold sodium thiomalate (Aurolate) is used to treat rheumatoid arthritis resistant to conventional therapy. Arsenic trioxide (Trisenox) is an antineoplastic.