Nokea
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.
You may also like to solve these questions
The nurse is caring for a client with a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?
- A. Alginate
- B. Dry gauze
- C. Hydrocolloid
- D. Transparent
Correct Answer: C
Rationale: Hydrocolloid dressings are appropriate for shallow, partial-thickness pressure ulcers as they maintain a moist environment to promote healing.
The nurse reviews the pathophysiology of burns with students. It would be correct to state which hormone alterations occur during a major burn. Select all that apply.
- A. Increased secretion of epinephrine
- B. Increased secretion of antidiuretic hormone (ADH)
- C. Increased secretion of aldosterone
- D. Decreased levels of glucose
- E. Increased secretion of norepinephrine
Correct Answer: A, B, C, E
Rationale: Major burns cause a stress response, increasing epinephrine, ADH, aldosterone, and norepinephrine to compensate for fluid loss and maintain homeostasis. Glucose levels increase, not decrease, due to stress-induced hyperglycemia.
The nurse is caring for a client with several severe pressure ulcers. Which laboratory result requires the nurse to intervene?
- A. Serum albumin level of 2.5 g/dL [3.5-5 g/dL]
- B. Serum potassium level of 4 mEq/L (mmol/L) [3.5 and 5.0 mEq/L (mmol/L)]
- C. Serum sodium level of 140 mEq/L (mmol/L) [135-145 mEq/L (mmol/L)]
- D. White blood cell count of 9,000 cells/uL (9x10%) [4,500-11,000 cells/uL, 3.5-10.5 × 10°/L]
Correct Answer: A
Rationale: A low serum albumin level (2.5 g/dL) indicates malnutrition, which impairs wound healing and requires intervention. Other lab values are within normal ranges.
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 is conducting a community health class on skin changes for older adults. It would be appropriate for the nurse to state which of the following are normal age-related changes? Select all that apply.
- A. Decreased dermal blood flow
- B. Development of actinic lentigo
- C. Degeneration of elastic fibers
- D. Loss of subcutaneous fat
- E. Increased epidermal thickness
Correct Answer: A, B, C, D
Rationale: Normal age-related skin changes include decreased dermal blood flow, actinic lentigo (age spots), degeneration of elastic fibers (leading to wrinkles), and loss of subcutaneous fat (thinner skin). Increased epidermal thickness is not typical; the epidermis thins with age.