Sie sind auf Seite 1von 11

WE The RN has assigned a client who has an open burn wound to the LPN.

Which instruction is most important for the RN to provide the LPN?

Administer the prescribed tetanus toxoid vaccine.

Assess wounds for signs of infection.

Encourage the client to cough and breathe deeply.

Wash hands on entering the client’s room.

Question 1 Explanation:
Infection can occur when microorganisms from another person or the
environment are transferred to the client. Although all the
interventions listed can help reduce the risk for infection, hand washing
is the most effective technique for preventing infection transmission.

Question 2


Three days after a burn injury, the client develops a temperature of 100° F,
white blood cell count of 15,000/mm3, and a white, foul-smelling discharge
from the wound. The nurse recognizes that the client is most likely exhibiting
symptoms of which condition?

Acute phase of the injury

Autodigestion of collagen

Granulation of burned tissue

Wound infection

Question 2 Explanation:
Color change, purulent, foul-smelling drainage, increased white blood
cell count, and fever could all indicate infection. These symptoms will
not be seen in the acute phase of the injury. Autodigestion of collagen
and granulation of tissue will not increase the body temperature or
cause foul-smelling wound discharge.
Question 3


Twelve hours after the client was initially burned, bowel sounds are absent in
all four abdominal quadrants. Which is the nurse’s best action?

Administers a laxative

Documents the finding

Increases the IV flow rate

Repositions the client onto the right side

Question 3 Explanation:
Decreased or absent peristalsis is an expected response during the
emergent phase of burn injury as a result of neural and hormonal
compensation to the stress of injury. No currently accepted
intervention changes this response. It is not the highest priority of care
at this time.

Question 4


What intervention will the nurse implement to reduce a client’s pain after a
burn injury?

Administering morphine 4 mg intravenously.

Administering hydromorphone (Dilaudid) 4 mg intramuscularly.

Applying ice to the burned area

Avoiding tactile stimulation

Question 4 Explanation:
Drug therapy for pain management requires opioid and nonopioid
analgesics. The IV route is used because of problems with absorption
from the muscle and stomach. Tactile stimulation can be used for pain
management. For the client to avoid shivering, the room must be kept
warm and heat should be applied.

Question 5


What statement indicates the client needs further education regarding the
skin grafting (allografting)?

“Because the graft is my own skin, there is no chance it won’t ‘take.'”

“For the first few days after surgery, the donor sites will be painful.”

“I will have some scarring in the area when the skin is removed for

“I am still at risk for infection after the procedure.”

Question 5 Explanation:
Factors other than tissue type, such as circulation and infection,
influence whether and how well a graft will work. The client should be
prepared for the possibility that not all grafting procedures will be
successful. The donor sites will be painful after the surgery, there can
be scarring in the area where skin is removed for grafting, and the
client is still at risk for infection.

Question 6


When providing care for a client with an acute burn injury, which nursing
intervention is most important to prevent infection by autocontamination?

Avoiding sharing equipment such as blood pressure cuffs between clients

Changing gloves between wound care on different parts of the client’s body

Using the closed method of burn wound management

Using proper and consistent handwashing

Question 6 Explanation:
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 carrying
out wound care on different parts of the client’s body can prevent

Question 7


Which assessment finding assists the nurse in confirming inhalation injury?

Brassy cough

Decreased blood pressure



Question 7 Explanation:
Brassy cough and wheezing are some signs seen with inhalation injury.
All the other symptoms are seen with carbon monoxide poisoning.

Question 8


Which finding indicates that fluid resuscitation has been successful for a
client with a burn injury?

Hematocrit = 60%

Heart rate = 130 beats/min

Increased peripheral edema

Urine output = 50 mL/hr

Question 8 Explanation:
The fluid remobilization phase improves renal blood flow, increases
diuresis, and restores blood pressure and heart rate to more normal
levels, as well as laboratory values.

Question 9


Which finding indicates to the nurse that a client with a burn injury has a
positive perception of his appearance?

Allowing family members to change his dressings

Discussing future surgical reconstruction

Performing his own morning care

Wearing the pressure dressings as ordered

Question 9 Explanation:
Indicators that the client with a burn injury has a positive perception of
his appearance includes the 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 increase self-perception.

Question 10


Which finding indicates to the nurse that the client understands the
psychosocial impact of his severe burn injury?

“It is normal to feel depressed.”

“I will be able to go back to work immediately.”

“I will not feel anger about my situation.”

“Once I get home, things will be normal.”

Question 10 Explanation:
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. Feelings of 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

Question 11


Which finding is characteristic during the emergent period after a deep full
thickness burn injury?

Blood pressure of 170/100 mm Hg

Foul-smelling discharge from wound

Pain at site of injury

Urine output of 10 mL/hr

Question 11 Explanation:
During the fluid shift of the emergent period, blood flow to the kidney
may not be adequate for glomerular filtration. As a result, urine output
is greatly decreaseD. Foul-smelling discharge does not occur during
the emergent phase and blood pressure is usually low. Pain does not
occur with deep full-thickness burns.

Question 12


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?
Decreased Tissue Perfusion

Disturbed Body Image

Risk for Disuse Syndrome

Risk for Ineffective Breathing Pattern

Question 12 Explanation:
During the emergent phase, fluid shifts into interstitial tissue in burned
areas. When the burn is circumferential on an extremity, the swelling
can compress blood vessels to such an extent that circulation is
impaired distal to the injury, causing decreased tissue perfusion and
necessitating the intervention of an escharotomy. Chemical burns do
not cause inhalation injury and a disrupted breathing pattern.
Disturbed body image and disuse syndrome can develop. However,
these are not priority diagnoses at this time.

Question 13


Which laboratory result, obtained on a client 24 hours post-burn injury, will

the nurse report to the physician immediately?

Arterial pH, 7.32

Hematocrit, 52%

Serum potassium,7.5 mmol/L (mEq/L)

Serum sodium, 131 mmol/L (mEq/L)

Question 13 Explanation:
The serum potassium level is changed to the degree that serious life-
threatening responses could result. With such a rapid rise in the
potassium level, the client is at high risk for experiencing severe
cardiac dysrhythmias and death. All the other findings are abnormal,
but not to the same degree of severity, and would be expected in the
emergent phase after a burn injury.
Question 14


Which nursing intervention is likely to be most helpful in providing adequate

nutrition while the client is recovering from a thermal burn injury?

Allowing the client to eat whenever he or she wants

Beginning parenteral nutrition high in calories

Limiting calories to 3000 kcal/day

Providing a low-protein, high-fat diet

Question 14 Explanation:
Clients should request food whenever they think that they can eat, not
just according to the hospital’s standard meal schedule. The nurse
needs to work with a nutritionist to provide a high-calorie, high-protein
diet to help with wound healing. Clients who can eat solid foods should
ingest as many calories as possible. Parenteral nutrition may be given
as a last resort because it is invasive and can lead to infectious and
metabolic complications.

Question 15


Which statement best exemplifies the client’s understanding of rehabilitation

after a full-thickness burn injury?

“I am fully recovered when all the wounds are closed.”

“I will eventually be able to perform all my former activities.”

“My goal is to achieve the highest level of functioning that I can.”

“There is never full recovery from a major burn injury.”

Question 15 Explanation:
Although a return to pre-burn functional levels is rarely possible,
burned clients are considered fully recovered or rehabilitated when
they have achieved their highest possible level of physical, social, and
emotional functioning. The technical rehabilitative phase of
rehabilitation begins with wound closure and ends when the client
returns to her or his highest possible level of functioning.

Question 16


Which statement indicates that a client with facial burns understands the
need to wear a facial pressure garment?

“My facial scars should be less severe with the use of this mask.”

“The mask will help protect my skin from sun damage.”

“This treatment will help prevent infection.”

“Using this mask will prevent scars from being permanent.”

Question 16 Explanation:
The purpose of wearing the pressure garment over burn injuries for up
to 1 year is to prevent hypertrophic scarring and contractures from
forming. Scars will still be present. Although the mask does provide
protection of sensitive, newly healed skin and grafts from sun
exposure, this is not the purpose for wearing the mask. The pressure
garment will not alter the risk for infection.

Question 17


The client with a dressing covering the neck is experiencing some respiratory
difficulty. What is the nurse’s best first action?

Administer oxygen.

Loosen the dressing.

Notify the emergency team.

Document the observation as the only action.

Question 17 Explanation:
Respiratory difficulty can arise from external pressure. The first action
in this situation would be to loosen the dressing and then reassess the
client’s respiratory status.

Question 18


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?

Increased wound pain 30 to 40 minutes after drug application

Presence of small, pale pink bumps in the wound beds

Decreased white blood cell count

Increased serum creatinine level

Question 18 Explanation:
Gentamicin does not stimulate pain in the wound. The small, pale pink
bumps in the wound bed are areas of re-epithelialization and not an
adverse reaction. 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

Question 19


Which intervention is most important to use to prevent infection by

autocontamination in the burned client during the acute phase of recovery?
Changing gloves between wound care on different parts of the client’s body.

Avoiding sharing equipment such as blood pressure cuffs between clients.

Using the closed method of burn wound management.

Using proper and consistent handwashing.

Question 19 Explanation:
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 carrying
out wound care on different parts of the client’s body can prevent

Question 20


The burned client relates the following history of previous health problems.
Which one should alert the nurse to the need for alteration of the fluid
resuscitation plan?

Seasonal asthma

Hepatitis B 10 years ago

Myocardial infarction 1 year ago

Kidney stones within the last 6 month

Question 20 Explanation:
It is likely the client has a diminished cardiac output as a result of the
old MI and would be at greater risk for the development of congestive
heart failure and pulmonary edema during fluid resuscitation.

See Also