1
Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?
Answer: Crystalloids
Questions
2
The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action?
Answer: Loosen the dressing.
3
The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action?
Answer: Notify the emergency team.
4
Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action?
Answer: Document the finding as the only action.
5
On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury–related response?
Answer: Fluid shift
6
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action?
Answer: Document the finding as the only action.
7
Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?
Answer: Increased urine output, decreased urine specific gravity
8
What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm?
Answer: Risk for Disuse Syndrome
9
All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately?
Answer: Serum potassium 7.5 mmol/L (mEq/L)
10
The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission?
Answer: Heart rate and rhythm
