Nokea
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply.
- A. Perform meticulous hand hygiene.
- B. Use sterile gloves for wound care.
- C. Wear gown and mask during procedures.
- D. Change central lines once a week.
- E. Administer antibiotics as prescribed.
Correct Answer: A,B,C,E
Rationale: Hand hygiene, sterile gloves, gown/mask, and antibiotics prevent infection in extensive burns. Weekly central line changes are not standard; daily assessment is preferred.
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Which response by the nurse is best at this time?
- A. I'm sure you will look absolutely gorgeous.
- B. I didn't think you were unattractive before.
- C. Your face is swollen with bruises around the eyes.
- D. Your personality is more important than your looks.
Correct Answer: C
Rationale: An honest response about expected swelling prepares the client for recovery.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?
- A. A 22-gauge intravenous line with normal saline infusing.
- B. Wounds covered with moist sterile dressings.
- C. No intravenous pain medication.
- D. Ensure adequate peripheral circulation to both feet.
Correct Answer: D
Rationale: Ensuring peripheral circulation prevents ischemic complications during transfer. A 22-gauge IV is too small for major burns, moist dressings are inappropriate for full-thickness burns, and IV pain medication is needed.
The client is complaining of burning, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement?
- A. Transfer the client to the ED for a cardiac work-up.
- B. Inform the client that the nurse can’t see anything.
- C. Administer a nonnarcotic analgesic to the client.
- D. Ask the client if he or she has ever had chickenpox.
Correct Answer: D
Rationale: Burning pain along dermatomes without visible lesions suggests early herpes zoster, linked to prior chickenpox. Cardiac work-up, dismissal, or analgesics are premature.
Before the examination can be completed, which type of eye medication would the nurse instill in the client's eye to dilate the pupil and temporarily paralyze the ciliary muscle?
- A. Pilocarpine (Pilocar)
- B. Dipivefrin (Propine)
- C. Gentamicin (Genoptic)
- D. Cyclopentolate solution (Cyclogyl)
Correct Answer: D
Rationale: Cyclopentolate is a cycloplegic agent that dilates the pupil and paralyzes the ciliary muscle for retinoscopy.
The nurse is obtaining a preoperative health history on the client scheduled for revision of facial scars. Which client comment indicates an increased risk for a poor cosmetic outcome?
- A. I haven't had anything to eat or drink since 10 pm last night.
- B. I'm nervous about surgery; what if the surgery doesn't work?
- C. My high blood pressure is controlled with lisinopril.
- D. I plan to continue taking diclofenac for pain control.
Correct Answer: D
Rationale: Diclofenac (Voltaren) is an NSAID; increased bleeding tendency and increased sensitivity to sunlight are side effects that may inhibit achieving optimal cosmetic outcomes. Fasting is standard practice. Nervousness does not affect cosmetic outcomes. Controlled hypertension poses no significant risk.