Questions
1
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?
Answer: Increased serum creatinine level
2
The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action?
Answer: Notify the burn emergency team
3
Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?
Answer: Changing gloves between wound care on different parts of the client’s body.
4
When should ambulation be initiated in the client who has sustained a major burn?
Answer: As soon as possible after resolution of the fluid shift
5
What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?
Answer: “Because the graft is my own skin, there is no chance it won’t ‘take’.”
6
Which statement by the client indicates correct understanding of rehabilitation after burn injury?
Answer: “I will be fully recovered when I achieve the highest possible level of functioning that I can.”
7
Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment?
Answer: “My facial scars should be less severe with the use of this mask.”
8
What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?
Answer: Impaired Adjustment
9
Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
Answer: Permeability of capillary walls
10
Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:
Answer: Maintain room humidity below 40%
