Nokea
The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?
- A. I get my chimney sweep every other year.
- B. My hot water heater is set at 120 degrees.
- C. Sometimes I wake up at night and smoke.
- D. I use a space heater when it gets below zero.
Correct Answer: C
Rationale: House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes, as this could involve smoking in bed, which poses a significant fire risk if the person falls back asleep with a lighted cigarette.
You may also like to solve these questions
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.
A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next?
- A. Administer furosemide (Lasix).
- B. Perform chest physiotherapy.
- C. Document and reassess in an hour.
- D. Place the client in an upright position.
Correct Answer: D
Rationale: These symptoms suggest pulmonary edema, possibly from fluid resuscitation. Placing the client in an upright position can relieve lung congestion immediately while other measures are planned.
A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)
- A. Music as a distraction
- B. Tactile stimulation
- C. Massage to injury sites
- D. Cold compresses
- E. Increasing client control
Correct Answer: A,B,E
Rationale: Nonpharmacologic measures like music therapy, tactile stimulation, and increasing client control can help manage anxiety and pain. Massage to injury sites and cold compresses are not appropriate for burn injuries.
A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.)
- A. Provide at least 5000 kcal/day.
- B. Start an oral diet on the first day.
- C. Administer a diet high in protein.
- D. Collaborate with a registered dietitian.
- E. Offer frequent high-calorie snacks.
Correct Answer: A,C,D,E
Rationale: Burn patients require a high-calorie (at least 5000 kcal/day), high-protein diet, frequent snacks, and collaboration with a dietitian to meet nutritional needs. Starting an oral diet on the first day may not be feasible due to medical instability.
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.