When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by auto contamination? A. Avoiding sharing equipment such as blood pressure cuffs between clients B. Changing gloves between wound care on different parts of the client’s body C. Using the closed method… Read More »
Nurse Cirie is caring for a client who suffered a smoke inhalation injury. The carbon monoxide report reveals a level of 35%. Based on the level, which of the following signs should the nurse expect in the client? A. Seizure B. Confusion C. Flushing D. Coma Correct… Read More »
The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response? A. “To increase urine output and prevent kidney damage.” B. “To stimulate intestinal movement and prevent abdominal bloating.”… Read More »
The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action? A. Assess level of consciousness and pupillary reactions. B. Ask the client at what time food or liquid was last consumed. C. Auscultate breath sounds over the trachea and mainstem bronchi. D. Measure… Read More »
The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury? A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Full-thickness deep Correct Answer: C. Partial-thickness deep Deep partial-thickness… Read More »
Which assessment finding assists the nurse in confirming inhalation injury? A. Brassy cough B. Decreased blood pressure C. Nausea D. Headache Correct Answer: A. Brassy cough Brassy cough and wheezing are some signs seen with inhalation injury. Damage to airway tissue causes increased mucus production, edema, denudation… Read More »
A client is brought to the emergency unit with third-degree burns on the posterior trunk, right arm, and left posterior leg. Using the Rule of Nines, what is the total body surface area (TBSA) that has been burned? A. 36% B. 54% C. 45% D. 27% Correct… Read More »
At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? A. Immediately following the injury B. During the fluid shift C. During fluid remobilization D. During the late acute phase Correct Answer: C. During fluid remobilization Hypokalemia is most… Read More »
Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds? A. Handwashing on entering the client’s room B. Encouraging the client to cough and deep breathe C. Administering the prescribed tetanus toxoid vaccine D. Changing gloves between cleansing… Read More »
The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a “small amount of pain.” How will the nurse categorize this injury? A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Superficial Correct Answer:… Read More »