Question 1

A nurse administers topical gentamicin sulfate (Garamycin)to a client's burn injury.Which laboratory value should the nurse monitor while the client is prescribed this therapy?

Accepted Answer

Gentamicin is nephrotoxic,and sufficient amounts can be absorbed through burn wounds to affect kidney function.Any client receiving gentamicin by any route should have kidney function monitored.Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

Question 2

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing.Which action should the nurse take first?

Accepted Answer

Inhalation injuries are present in 7% of clients admitted to burn centers.Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury.Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation.Knowing the level of consciousness is important in assessing oxygenation to the brain.Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration).However,assessing for air exchange is the most important intervention at this time.Measuring abdominal girth is not relevant in this situation.

Question 3

The nurse is caring for a client with an acute burn injury.Which action should the nurse take to prevent infection by autocontamination?

Accepted Answer

Autocontamination is the transfer of microorganisms from one area to another area of the same client's 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 client's body can prevent autocontamination.

Question 4

The nurse teaches burn prevention to a community group.Which statement by a member of the group should cause the nurse the greatest concern?

Accepted Answer

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.The nurse needs to question this person about whether he or she gets out of bed to do so,or if this person stays in bed,which could lead to falling back asleep with a lighted cigarette.Although it is recommended to have chimneys swept every year,skipping a year does not pose as much danger as smoking in bed,particularly if the person does not burn wood frequently.Water heaters should be set below 140° F.Space heaters should be used with caution,and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.

Question 5

The nurse assesses a client who has a severe burn injury.Which statement indicates the client understands the psychosocial impact of a severe burn injury?

Accepted Answer

During the recovery period,and for some time after discharge from the hospital,clients with severe burn injuries are likely to have psychological problems that require intervention.Depression is one of these problems.Grief,loss,anxiety,anger,fear,and guilt are all normal feelings that can occur.Clients need to know that problems of physical care and psychological stresses may be overwhelming.

Question 6

A nurse teaches a client being treated for a full-thickness burn.Which statement should the nurse include in this client's discharge teaching?

Accepted Answer

Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client.All of the other options are important in the rehabilitation stage.However,dressing changes have priority.

Question 7

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?

Accepted Answer

Brassy cough and wheezing are some of the signs seen with inhalation injury.The first action by the nurse is to give the client oxygen.Clients with possible inhalation injury also need continuous pulse oximetry.Ice chips and humidified room air will not help the problem,and antitussives are not warranted.

Question 8

A nurse prepares to administer intravenous cimetidine (Tagamet)to a client who has a new burn injury.The client asks,"Why am I taking this medication?" How should the nurse respond?

Accepted Answer

Ulcerative gastrointestinal disease (Curling's ulcer)may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier.This process occurs because of the sympathetic nervous system stress response.Cimetidine is a histamine? blocker and inhibits the production and release of hydrochloric acid.Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage.

Question 9

A nurse cares for a client with burn injuries.Which intervention should the nurse implement to appropriately reduce the client's pain?

Accepted Answer

Drug therapy for pain management requires opioid and nonopioid analgesics.The IV route is used because of problems with absorption from the muscle and the stomach.For the client to avoid shivering,the room must be kept warm,and ice should not be used.Ice would decrease blood flow to the area.Tactile stimulation can be used for pain management.

Question 10

A nurse cares for a client who has burn injuries.The client's wife asks,"When will his high risk for infection decrease?" How should the nurse respond?

Accepted Answer

Intact skin is a major barrier to infection and other disruptions in homeostasis.No matter how much time has passed since the burn injury,the client remains at high risk for infection as long as any area of skin is open.Although the other options are important goals in the client's recovery process,they are not as important as skin closure to decrease the client's risk for infection.

Question 11

A nurse cares for a client with burn injuries from a house fire.The client is not consistently oriented and reports a headache.Which action should the nurse take?

Accepted Answer

These manifestations are consistent with moderated carbon monoxide poisoning.This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space.The other options will not provide information related to carbon monoxide poisoning.

Question 12

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face,arms,and chest.Which assessment finding should alert the nurse to a potential complication?

Accepted Answer

A significant loss of fluid occurs with burn injuries,and fluids must be replaced to maintain hemodynamics.If fluid replacement is not adequate,the client may become hypotensive and have decreased perfusion of organs,including the brain and kidneys.A low urine output is an indication of poor kidney perfusion.The other manifestations are not complications of burn injuries.

Question 13

A nurse reviews the laboratory results for a client who was burned 24 hours ago.Which laboratory result should the nurse report to the health care provider immediately?

Accepted Answer

The serum potassium level is changed to the degree that serious life-threatening responses could result.With such a rapid rise in potassium level,the client is at high risk for experiencing severe cardiac dysrhythmias and death.All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

Question 14

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula.The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr.Which prescription should the nurse question?

Accepted Answer

The plan of care for a client with a burn includes fluid and electrolyte resuscitation.Furosemide would be inappropriate to administer.Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula.However,needs vary among clients,and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr.Based on this client's inadequate urine output,fluids need to be increased,urine output needs to be monitored hourly,and electrolytes should be evaluated to ensure appropriate fluids are being infused.

Question 15

A nurse assesses a client who has a burn injury.Which statement indicates the client has a positive perspective of his or her appearance?

Accepted Answer

Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part.Self-care activities such as morning care foster feelings of self-worth,which are closely linked to body image.Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance.Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

Question 16

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?

Accepted Answer

Pulmonary edema can result from fluid resuscitation given for burn treatment.This can occur even in a young healthy person.Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out.Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded,a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore,Lasix would not be appropriate.Chest physiotherapy will not get rid of fluid.

Question 17

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm.How should the nurse document the percentage of the client's body that sustained burns?

Accepted Answer

According to the rule of nines,the posterior trunk,anterior trunk,and legs each make up 18% of the total body surface.The head,neck,and arms each make up 9% of total body surface,and the perineum makes up 1%.In this case,the client received burns to the back (18%)and one arm (9%),totaling 27% of the body.

Question 18

A nurse cares for a client who has facial burns.The client asks,"Will I ever look the same?" How should the nurse respond?

Accepted Answer

Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state.The nurse should provide accurate information that includes something to hope for.Pressure dressings prevent further scarring; they cannot remove scars.The client and the family should be taught the expected cosmetic outcomes.

Question 19

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?

Accepted Answer

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.

Question 20

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth.Four hours later the wheezing is no longer heard.Which action should the nurse take?

Accepted Answer

Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air.When this occurs,wheezing is no longer heard,and neither are breath sounds.These clients can lose their airways very quickly,so prompt action is needed.The client requires establishment of an emergency airway.Swelling usually precludes intubation.The other options do not address this emergency situation.

Quiz 26: Care of Patients with Burns

A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury.Which laboratory value should the nurse monitor while the client is prescribed this therapy?