Question 1

A student nurse is assisting a registered nurse in caring for a client with deep partial thickness burns on almost 60% of the body. Which action of the student nurse requires the need for further teaching?

Accepted Answer

Encouraging a low liquid diet in a client with deep partial thickness burns on almost 60% of the body is not appropriate. The client needs to be encouraged to consume high-calorie and high-protein liquid diets to promote healing and prevent infection. The student nurse needs further teaching regarding the appropriate diet for a client with burns.

Question 2

While caring for a client with thermal injury of approximately 50% of the total body surface area (TBSA), a nurse observes stridor in the client. Which is the priority nursing intervention for this client?

Accepted Answer

Stridor is a high-pitched, wheezing sound that indicates obstruction or narrowing of the airway. Intubating the client is the priority nursing intervention because it helps secure the airway and provides oxygenation to the client. Elevating the affected extremities is not relevant to this situation. Administering IV fluids is important, but it is not the priority in this case. Beginning cardiopulmonary resuscitation may be necessary in case of cardiac arrest, but it is not the first intervention to consider for stridor.

Question 3

A nurse is caring for a client with thermal burns. The client has a respiratory rate of 14 breaths per minute. Which nursing intervention is appropriate for this client?

Accepted Answer

C,D,E

Question 4

Which physiological change can be observed in the prodromal stage of radiation burns in a client who has been exposed to 200 rads?

Accepted Answer

In the prodromal stage of radiation burns with an exposure of 200 rads, pruritus (itching) is the most common physiological change observed. Skin ulcers, necrosis of tissue, and permanent damage to hair follicles are observed in the acute stage of radiation burns.

Question 5

After assessing a client with burns, a nurse sees that there is no need for a diagnostic evaluation of these burns. Which type of burns did the nurse observe on the client?

Accepted Answer

Superficial burns, also known as first-degree burns, only affect the outer layer of the skin and do not require diagnostic evaluation.

Question 6

A client with partial thickness burns is hemodynamically unstable. Which route of administration of analgesics is preferred in the client?

Accepted Answer

Intravenous administration of analgesics is preferred in a hemodynamically unstable client because it ensures rapid absorption and onset of action. This is especially important in a client with partial thickness burns who may experience significant pain and require immediate pain relief. Other routes like oral, subcutaneous or intramuscular may not be effective enough or could potentially cause further harm to the client's health.

Question 7

While reviewing acid-base analysis reports of a client who has electrical burns, a nurse finds metabolic acidosis in the client. Which medication does the nurse expect to be prescribed for the client?

Accepted Answer

Sodium bicarbonate is commonly used to correct metabolic acidosis, which is indicated in the client's acid-base analysis report. Hydromorphone is an opioid pain medication, while silver sulfadiazine and mafenide acetate are topical medications used for wound healing and preventing infection in burn injuries.

Question 8

While assessing a client, a nurse finds that the skin on the wrist appears pearl-pink, wet, and blistered. On further assessment, the nurse finds that the client's dermis is exposed, extremely tender, and painful due to scalds. What does the nurse infer from these findings?

Accepted Answer

The description of the skin as pearl-pink, wet, and blistered with the dermis exposed and extremely tender indicates superficial partial thickness burns. These burns affect the epidermis and part of the dermis, leading to the symptoms described.

Question 9

While caring for a client after a thermal injury a nurse finds that the client is showing signs and symptoms of hyperkalemia. Which is the most important nursing intervention for this client?

Accepted Answer

Monitoring continuously through an electrocardiogram is the most important nursing intervention for a client with hyperkalemia as this condition can cause life-threatening cardiac arrhythmias. Administering oral fluids may be helpful in some cases, but it is not the most important intervention for hyperkalemia. Applying a topical antibiotic on the burns and elevating the head of the bed do not address the hyperkalemia.

Question 10

While assessing a client, a nurse finds that a client's cheek epidermal skin is dry and reddened with blisters. The client reports pain and tenderness at the area. On further assessment, the nurse finds that there is no breakage in the epidermal skin layer. Which reason does the nurse suspect behind this condition in the client?

Accepted Answer

Overexposure to the sun can cause the skin to become dry, reddened, and blistered without necessarily breaking the skin, consistent with the symptoms described.

Question 11

While caring for a client with full thickness burns, a nurse finds that the client is presenting with the signs of Curling's ulcer. Which class of medication does the nurse anticipate in the client's prescription?

Accepted Answer

The answer of While caring for a client with full...

Question 12

After reviewing the laboratory reports of a client, a nurse confirms the presence of aplastic bone marrow in the client. Which intervention is most beneficial for the client?

Accepted Answer

The answer of After reviewing the laboratory reports of a...

Question 13

A nurse is teaching a client preventive measures for scalds. Which statement should the nurse include in the teaching plan to ensure safety?

Accepted Answer

Setting the temperature of the water heater below 140°F can prevent scalds by reducing the risk of overheated water. Wearing cotton gloves or applying moisturizer may not provide adequate protection. Applying oil to the container may actually increase the risk of spills and burns.

Question 14

A nurse is caring for a client who has severe bleeding from the right hand due to an injury at work. On further assessment, the nurse also finds that the client works in a uranium mine. Which is a priority nursing intervention for the client?

Accepted Answer

The priority nursing intervention for the client is to remove and bag the client's clothes and shoes to prevent any radioactive contamination from the uranium mine. This action will also protect healthcare workers from exposure. Timely administration of intravenous fluids and scheduling surgery can be done after ensuring safety from radiation exposure. Enquiring about insurance coverage is not a priority intervention in this situation.

Question 15

While assessing a client, a nurse finds that the client has superficial burns. Which treatment does the nurse anticipate to be beneficial for this client?

Accepted Answer

Analgesics are used to manage pain, which is a common symptom of superficial burns.

Question 16

After assessing the burns in a client, a nurse documents "first-degree burns" in the client's medical records. Which finding in the client supports the nurse's documentation?

Accepted Answer

First-degree burns, also known as superficial burns, only affect the top layer of skin, causing redness and pain but not blistering or peeling.

Question 17

While assessing a client, a nurse finds that the client's skin has a dry, leathery, and white-colored area near the elbow. The area does not blanche on applying pressure. The nurse also finds that the subcutaneous layer of the client's skin is injured due to a burn. Which information does the nurse provide to the client?

Accepted Answer

The description of the burn, including the involvement of the subcutaneous layer and the appearance of the skin, suggests a deep partial-thickness or full-thickness burn. These types of burns do not heal quickly and often require weeks to months for healing, depending on the severity and treatment.

Question 18

Which zone exhibits the greatest degree of thermal injury within the skin?

Accepted Answer

The zone of coagulation is the area of the burn that exhibits the greatest degree of thermal injury, characterized by complete tissue destruction and irreversible damage. The other zones, including the zone of stasis and zone of hyperemia, may also show varying degrees of injury, but not to the extent of the zone of coagulation. Therefore, choice (C) is the correct answer.

Question 19

While assessing a child, a nurse finds a characteristic gray coloring on 30% of the total body surface area (TBSA). On communicating with the parent, the nurse finds that the child has ingested toilet bowl cleaner accidentally. Which condition does the nurse expect in the child?

Accepted Answer

The presence of gray coloring and accidental ingestion of toilet bowl cleaner indicate chemical burns.

Question 20

A nurse is caring for a client with thermal burns on 30% of the body in an emergency department. Which nursing intervention prevents the risk of burn shock in the client?

Accepted Answer

Adequate fluid resuscitation is the primary nursing intervention to prevent burn shock in a client with thermal burns. It helps to maintain the client's blood volume and perfusion to vital organs, thereby preventing hypovolemia and shock. Elevating the head of the bed or applying silver nitrate ointment is not directly related to preventing burn shock. Administering potassium supplements may be necessary depending on the client's laboratory values, but it is not directly related to preventing burn shock.

Quiz 42: Burns