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Nursing care for Burns

Nursing care for Burns

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Published by: jimillum lomdonchrista on Apr 05, 2009
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01/27/2015

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Interventions for Clients with BurnsMULTIPLE CHOICE1.The newly admitted client has burns on both legs. The burned areasappear white and leather-like. No blisters or bleeding are present, and the clientstates that he or she has little pain. How should this injury be categorized?A.SuperficialB.Partial-thickness superficialC.Partial-thickness deepD.Full thicknessANS:AThe characteristics of the wound meet the criteria for a full-thickness injury(color that is black, brown, yellow, white or red; no blisters; pain minimal;outer layer firm and inelastic).DIF:Cognitive Level: Application or higherTOP:Nursing Process Step: AssessmentMSC:Client Needs Category: Safe, Effective Care Environment/PhysiologicalIntegrity;2.The newly admitted client has a large burned area on the right arm. Theburned area appears red, has blisters, and is very painful. How should this injurybe categorized?A.SuperficialB.Partial-thickness superficialC.Partial-thickness deepD.Full thicknessANS:BThe characteristics of the wound meet the criteria for a superficial partial-thickness injury (color that is pink or red; blisters; pain present and high).DIF:Cognitive Level: Application or higherTOP:Nursing Process Step: AssessmentMSC:Client Needs Category: Safe, Effective Care Environment/PhysiologicalIntegrity; 3.The burned client newly arrived from an accident scene is prescribed toreceive 4 mg of morphine sulfate by IV push. What is the most important reason toadminister the opioid analgesic to this client by the intravenous route?A.The medication will be effective more quickly than if given intramuscularly.B.It is less likely to interfere with the client’s breathing and oxygenation.C.The danger of an overdose during fluid remobilization is reduced.D.The client delayed gastric emptying.ANS:CAlthough providing some pain relief has a high priority, and giving the drug bythe IV route instead of IM, SC, or orally does increase the rate of effect, themost important reason is to prevent an overdose from accumulation of drug in theinterstitial space during the fluid shift of the emergent phase. When edema ispresent, cumulative doses are rapidly absorbed when the fluid shift is resolving.This delayed absorption can result in lethal blood levels of analgesics.
 
DIF:Cognitive Level: ComprehensionTOP:Nursing Process Step: Implementation/InterventionMSC:Client Needs Category: Safe, Effective Care Environment;4.Which vitamin deficiency is most likely to be a long-term consequenceof a full-thickness burn injury?A.Vitamin AB.Vitamin BC.Vitamin CD.Vitamin DANS:DSkin exposed to sunlight activates vitamin D. Partial-thickness burns reduce theactivation of vitamin D. Activation of vitamin D is lost completely in full-thickness burns.DIF:Cognitive Level: KnowledgeTOP:Nursing Process Step: N/AMSC:Client Needs Category: Health Promotion and Maintenance5.Which client factors should alert the nurse to potential increasedcomplications with a burn injury?A.The client is a 26-year-old male.B.The client has had a burn injury in the past.C.The burned areas include the hands and perineum.D.The burn took place in an open field and ignited the client's clothing.ANS:CBurns of the perineum increase the risk for sepsis. Burns of the hands requirespecial attention to ensure the best functional outcome.DIF:Cognitive Level: ComprehensionTOP:Nursing Process Step: AssessmentMSC:Client Needs Category: Physiological Integrity/Safe, Effective CareEnvironment;6.The burned client is ordered to receive intravenous cimetidine, an H2histamine blocking agent, during the emergent phase. When the client's family askswhy this drug is being given, what is the nurse’s best response?A.“To increase the urine output and prevent kidney damage.”B.“To stimulate intestinal movement and prevent abdominal bloating.”C.“To decrease hydrochloric acid production in the stomach and preventulcers.”D.“To inhibit loss of fluid from the circulatory system and preventhypovolemic shock.”ANS:CUlcerative gastrointestinal disease may develop within 24 hours after a severeburn as a result of increased hydrochloric acid production and decreased mucosalbarrier. Cimetidine inhibits the production and release of hydrochloric acid.DIF:Cognitive Level: Application or higherTOP:Nursing Process Step: Implementation/InterventionMSC:Client Needs Category: Safe, Effective Care Environment/Health Promotion andMaintenance;7.At what point after a burn injury should the nurse be most alert forthe complication of hypokalemia?
 
A.Immediately following the injuryB.During the fluid shiftC.During fluid remobilizationD.During the late acute phaseANS:CHypokalemia is most likely to occur during the fluid remobilization period as aresult of dilution, potassium movement back into the cells, and increasedpotassium excreted into the urine with the greatly increased urine output.DIF:Cognitive Level: ComprehensionTOP:Nursing Process Step: AssessmentMSC:Client Needs Category: Safe, Effective Care Environment;8.What clinical manifestation should alert the nurse to possible carbonmonoxide poisoning in a client who experienced a burn injury during a house fire?A.Pulse oximetry reading of 80%B.Expiratory stridor and nasal flaringC.Cherry red color to the mucous membranesD.Presence of carbonaceous particles in the sputumANS:CThe saturation of hemoglobin molecules with carbon monoxide and the subsequentvasodilation induces a “cherry red” color of the mucous membranes in theseclients. The other manifestations are associated with inhalation injury, but notspecifically carbon monoxide poisoning.DIF:Cognitive Level: Application or higherTOP:Nursing Process Step: AssessmentMSC:Client Needs Category: Safe, Effective Care Environment/PhysiologicalIntegrity;9.What clinical manifestation indicates that an escharotomy is needed ona circumferential extremity burn?A.The burn is full thickness rather than partial thickness.B.The client is unable to fully pronate and supinate the extremity.C.Capillary refill is slow in the digits and the distal pulse is absent.D.The client cannot distinguish the sensation of sharp versus dull in theextremity.ANS:CCircumferential eschar can act as a tourniquet when edema forms from the fluidshift, increasing tissue pressure and preventing blood flow to the distalextremities and increasing the risk for tissue necrosis. This problem is anemergency and, without intervention, can lead to loss of the distal limb. Thisproblem can be reduced or corrected with an escharotomy.DIF:Cognitive Level: ComprehensionTOP:Nursing Process Step: EvaluationMSC:Client Needs Category: Safe, Effective Care Environment;10.What additional laboratory test should be performed on any AfricanAmerican client who sustains a serious burn injury?A.Total proteinB.Tissue type antigensC.Prostate specific antigenD.Hemoglobin S electrophoresisANS:DSickle cell disease and sickle cell trait are more common among African Americans.

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