Chapter 26- iggy Flashcards
- 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?
a.
“Administer the prescribed tetanus toxoid vaccine.”
b.
“Assess the client’s wounds for signs of infection.”
c.
“Encourage the client to breathe deeply every hour.”
d.
“Wash your hands on entering the client’s room.”
ANS: D
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.
- The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?
a.
Use a disposable blood pressure cuff to avoid sharing with other clients.
b.
Change gloves between wound care on different parts of the client’s body.
c.
Use the closed method of burn wound management for all wound care.
d.
Advocate for proper and consistent handwashing by all members of the staff.
ANS: B
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.
- The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?
a.
“I get my chimney swept every other year.”
b.
“My hot water heater is set at 120 degrees.”
c.
“Sometimes I wake up at night and smoke.”
d.
“I use a space heater when it gets below zero.”
ANS: C
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 p
- A nurse cares for a client who has facial burns. The client asks, “Will I ever look the same?” How should the nurse respond?
a.
“With reconstructive surgery, you can look the same.”
b.
“We can remove the scars with the use of a pressure dressing.”
c.
“You will not look exactly the same but cosmetic surgery will help.”
d.
“You shouldn’t start worrying about your appearance right now.”
ANS: C
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.
- A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?
a.
“I will allow my spouse to change my dressings.”
b.
“I want to have surgical reconstruction.”
c.
“I will bathe and dress before breakfast.”
d.
“I have secured the pressure dressings as ordered.”
ANS: C
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.
- 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?
a.
“It is normal to feel some depression.”
b.
“I will go back to work immediately.”
c.
“I will not feel anger about my situation.”
d.
“Once I get home, things will be normal.”
ANS: A
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.
- 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?
a.
Apply oxygen and continuous pulse oximetry.
b.
Provide small quantities of ice chips and sips of water.
c.
Request a prescription for an antitussive medication.
d.
Ask the respiratory therapist to provide humidified air.
ANS: A
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.
- 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?
a.
“Tagamet stimulates intestinal movement so you can eat more.”
b.
“It improves fluid retention, which helps prevent hypovolemic shock.”
c.
“It helps prevent stomach ulcers, which are common after burns.”
d.
“Tagamet protects the kidney from damage caused by dehydration.”
ANS: C
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 histamine2 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.
- A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
a.
Assess the level of consciousness and pupillary reactions.
b.
Ascertain the time food or liquid was last consumed.
c.
Auscultate breath sounds over the trachea and bronchi.
d.
Measure abdominal girth and auscultate bowel sounds.
ANS: C
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.
- 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?
a.
Increase intravenous fluids by 100 mL/hr.
b.
Administer furosemide (Lasix) 40 mg IV push.
c.
Continue to monitor urine output hourly.
d.
Draw blood for serum electrolytes STAT.
ANS: B
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.
- 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?
a.
Arterial pH: 7.32
b.
Hematocrit: 52%
c.
Serum potassium: 6.5 mEq/L
d.
Serum sodium: 131 mEq/L
ANS: C
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.
- 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?
a.
Administer furosemide (Lasix).
b.
Perform chest physiotherapy.
c.
Document and reassess in an hour.
d.
Place the client in an upright position.
ANS: D
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.
- 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?
a.
“When the antibiotic therapy is complete.”
b.
“As soon as his albumin levels return to normal.”
c.
“Once we complete the fluid resuscitation process.”
d.
“When all of his burn wounds have closed.”
ANS: D
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.
- 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?
a.
Creatinine
b.
Red blood cells
c.
Sodium
d.
Magnesium
ANS: A
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.
- A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client’s pain?
a.
Administer the prescribed intravenous morphine sulfate.
b.
Apply ice to skin around the burn wound for 20 minutes.
c.
Administer prescribed intramuscular ketorolac (Toradol).
d.
Decrease tactile stimulation near the burn injuries.
ANS: A
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.
