The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order of priority?
1. ... [Show More] Checking for a patent airway
2. Maintaining effective circulation
3. Performing adequate fluid replacement
4. Caring for the burn wound
A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation?
1. Using a jaw-thrust maneuver to establish an airway
2. Providing bag-valve-mask (BVM) ventilation
3. Palpating for the presence of a radial pulse
4. Monitoring systolic blood pressure
5. Assessing the score of eye opening
6. Removing the clothing with scissors
the eye opening, voice, and pain status. The clothes of the client are removed with scissors to prevent fabric melting into the skin.
The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment?
1 Determining the level of mobility
Correct2 Removing the clothes of the client
3 Placing the client in recumbent position
4 Cleaning the wounds with antiseptic solution
The nurse should remove all clothing of the client with scissors to allow for thorough assessment; this
A registered nurse teaches a new orienting nurse about interventions to be followed for a client with burns due to inhalation injury. Which statement made by the new orienting nurse indicates the new nurse needs more orientation?
1 "I should administer intravenous analgesia."
Correct2 "I should check pulses distal to burns."
3 "I should prepare for an endotracheal intubation."
4 "I should anticipate the need for fiberoptic bronchoscopy."
Inhalation injury burns occur in the nose, mouth, throat, and airway. The peripheral and central pulses are assessed, but they are not considered distal to the burn. The nurse should administer intravenous analgesia. The nurse should anticipate both endotracheal intubation and a need for fiberoptic bronchoscopy.
The nurse teaches a client about strategies to reduce burn injuries. Which statement made by the client indicates the need for further teaching?
1 "I should never smoke in bed."
2 "I should never use gasoline to start a fire."
3 "I should never leave hot oil unattended while cooking."
Correct4 "I should never attend to burning candles near open curtains."
The client should never leave candles unattended near open curtains. The client should never smoke in bed, use gasoline to start a fire, or leave hot oil unattended while cooking.
A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? Select all that apply.
Correct2 Burn odor
3 Smoky breath
Correct4 Leathery skin
Correct5 Cardiac arrest
A client with electrical burns may have assessment findings such as burn odor, leathery skin, and cardiac arrest due to hypovolemia and electrical disturbances. Coughing and smoky breath are assessment findings associated with inhalational injuries.
A client who sustained burn injuries due to a fire and explosion has a carbon monoxide level of 14%. Which pathophysiologic risk is increased in the client?
Correct4 Slight breathlessness
Slight breathlessness may occur when the carbon monoxide level is 14%. Stupor and vertigo may result when the carbon monoxide level is in between 21% and 40%. When the level of carbon monoxide reaches between 41% and 60%, coma or convulsions may occur.
The nurse is caring for a client with a burn injury and suspects atelectasis and hypoxia. Which age-related changes should the nurse associate these findings?
1 Reduced mobility
2 Reduced healing time
Correct3 Reduced thoracic compliance
4 Reduced inflammatory and immune responses
The reduction in thoracic and pulmonary compliance may increase the risk of atelectasis and hypoxia. Reduced mobility increases the risk for burn injuries. Reduced healing would have longer time with open areas, which results in greater risks for infection, metabolic derangements, and loss of function from [Show Less]