Which finding is characteristic during the emergent period after a deep full-thickness burn injury? A. Blood pressure of 170/100 mm Hg B. Foul-smelling discharge from wound C. Pain at site of injury D. Urine output of 10 mL/hr Correct Answer: D. Urine output of 10 mL/hr During… Read More »
Nurse Troyzan has just received the change-of-shift report in the burn unit. Which of the following client requires the most immediate care? A. A 50-year-old who was admitted with electrical burns 24 hours ago and has a serum potassium level of 5 mEq/L. B. A 40-year-old with partial-thickness leg burns which has a… Read More »
Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? A. Colloids B. Crystalloids C. Fresh-frozen plasma D. Packed red blood cells Correct Answer: B. Crystalloids Although not universally true, most fluid resuscitation for burn… Read More »
During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? A. Increased wound pain 30 to 40 minutes after drug application B. Presence… Read More »
A 22-year-old female client with a full-thickness burn is being discharged to home after a month in the hospital. Her wounds are minimally opened and she will be receiving home care. Which nursing diagnosis has the highest priority? A. Acute Pain B. Deficient Diversional Activity C. Impaired Adjustment D. Imbalanced Nutrition:… Read More »
Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain? A. Decreased Tissue Perfusion B. Disturbed Body Image C. Risk for Disuse Syndrome D. Risk for Ineffective Breathing Pattern … Read More »
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Increased blood pressure B. Increased hematocrit levels C. Decreased heart rate D.… Read More »
The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action? A. Administer oxygen. B. Loosen the dressing. C. Notify the emergency team. D. Document the observation as the only action. Correct Answer: B. Loosen the dressing. Respiratory… Read More »
The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action? A. Nothing, because the findings are normal for clients during the… Read More »
The client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse’s best response? A. “Tagamet will stimulate intestinal movement.” B. “Tagamet can help prevent hypovolemic shock.” C. “This will help prevent stomach ulcers.” D. “This drug will help prevent kidney damage.”… Read More »