1. A nurse is caring for a client who has a superficial partial thickness burn. Which of the following is an
appropriate action for the nurse to
... [Show More] take?
A. Administer an IV infusion of 0.9% sodium chloride.
B. Apply cool, wet compresses to affected area.
C. Clean the affected area using a soft-bristle brush.
D. Administer morphine sulfate.
B
B. Applying cool, wet compresses stops the burn process. Therefore, this is an appropriate
action for the nurse to take.
2. A nurse is caring for a client who has major burns and suspected septic shock. Which of the following
findings are consistent with septic shock? (Select all that apply.)
A. Increased body temperature
B. Altered sensorium
C. Decreased capillary refill
D. Decreased urine output
E. Increased bowel sounds
A B D
A. Increased body temperature is a clinical manifestation of septic shock.
B. Altered sensorium is a clinical manifestation of septic shock.
D. Decreased urine output is a clinical manifestation of septic shock.
3. A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the
following is an appropriate nursing intervention to manage this client's pain?
A. Administer morphine sulfate IV via continuous infusion.
B. Administer meperidine (Demerol) IM as needed.
C. Administer acetaminophen (Tylenol) PO every 4 hr.
D. Administer hydrocodone (Vicodin) PO every 6 hr.
A
A. Opioids administered IV via continuous infusion are recommended for clients who
have major burns.
4. A nurse is caring for a client who has a skin graft. Which of the following clinical manifestations
indicate infection? (Select all that apply.)
A. Green color to subcutaneous fat
B. Unstable body temperature
C. Generation of granulation tissue
D. Subeschar hemorrhage
E. Change in skin color around the affected area
A B D E
A. Green color to subcutaneous fat is a clinical manifestation of infection.
B. Unstable body temperature is a clinical manifestation of infection.
D. Subeschar hemorrhage is a clinical manifestation of infection.
E. A discoloration of the skin around the burn is a clinical manifestation of infection.
5. A nurse is caring for a client who has a moderate burn. Which of the following is an appropriate action
for the nurse to take?
A. Maintain immobilization of the affected area.
B. Expose affected area to the air.
C. Initiate a high-protein, high-calorie diet.
D. Implement contact isolation.
C
C. A high-protein, high-calorie diet is initiated to meet increased metabolic demands and
promote healing. [Show Less]