Ignatavicius: Medical-Surgical Nursing, 7th EditionChapter 28: Care of Patients ith !urns"est !an#M$%"IP%E C&'ICE1. The RN has assigned a client who has an open burn wound to the LPN. Which instructionis most important for the RN to provide the LPN?a. Administer the prescribed tetanus tooid vaccine.b. Assess wounds for signs of infection.c. !ave the client cough and breathe deepl".d. Wash hands on entering the client#s room.AN$% &'nfection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the ris( for infection) handwashing is the most effective techni*ue for preventing infection transmission.&'+% ,ognitive Level% Application-Appl"ing or higher R.+% N-AT/P% ,lient Needs ,ategor"% $afe and .ffective ,are .nvironment 0$afet" and 'nfection,ontrol1$tandard Precautions-Transmission23ased Precautions-$urgical Asepsis45$,% 'ntegrated Process% Nursing Process 0'mplementation46. When providing care for a client with an acute burn in7ur") which nursing intervention is most important to prevent infection b" autocontamination?a. Avoid sharing e*uipment such as blood pressure cuffs between clients.b. ,hange gloves between wound care on different parts of the client#s bod".c. 8se the closed method of burn wound management for all wound care.d. 8se proper and consistent handwashing b" all members of the staff.AN$% 3Autocontamination is the transfer of microorganisms from one area to another area of the same client#s bod") causing infection of a previousl" uninfected area. Although all techni*ues listed can help reduce the ris( for infection) onl" changing gloves between carr"ing out wound care on different parts of the client#s bod" can prevent autocontamination.&'+% ,ognitive Level% Application-Appl"ing or higher R.+% N-AT/P% ,lient Needs ,ategor"% $afe and .ffective ,are .nvironment 0$afet" and 'nfection,ontrol1$tandard Precautions-Transmission23ased Precautions-$urgical Asepsis45$,% 'ntegrated Process% Nursing Process 0'mplementation4,op"right 9 6:1;) 6:1:) 6::b. =5" hot water heater is set at about 16: degrees.>c. =$ometimes ' wa(e up at night and smo(e.>d. =' use a space heater when it gets below ?ero.>AN$% ,!ouse fires are a common occurrence and often lead to serious in7ur" or death. The nurse should be most concerned about a person who wa(es up at night and smo(es. The nurse needs to *uestion this person about whether he or she gets out of bed to do so) or if this person sta"s in bed) which could lead to falling bac( asleep with a lighted cigarette. Although it is recommended to have chimne"s swept ever" "ear) s(ipping a "ear does notpose as much danger as smo(ing in bed) particularl" if the person does not burn wood fre*uentl". Water heaters should be set below 1@:A +. $pace heaters should be used with caution) and the nurse ma" want to ensure that the person does not allow it to get near clothing or bedding. 3ut the most immediate concern is the person#s smo(ing upon wa(ing up at night.&'+% ,ognitive Level% Application-Appl"ing or higher R.+% N-AT/P% ,lient Needs ,ategor"% !ealth Promotion and 5aintenance 0Lifest"le ,hoices45$,% 'ntegrated Process% Teaching-Learning@. The nurse is conducting a home safet" class. 't is most important for the nurse to include which information in the teaching plan?a. !ave an escape route ever"one (nows about.b. Beep a smo(e detector in each bedroom.c. 8se space heaters instead of gas heaters.d. 8se carbon monoide detectors in the garage.AN$% 3.ver"one should use smo(e detectors and carbon monoide detectors in their home environment 07ust not in a garage4. Recommendations are that each bedroom should have a separate smo(e detector. $mo(e detectors should also be placed in the hallwa" of each stor") in the (itchen) in each stairwell) and b" each entrance. $pace heaters can be a causeof fire if clothing) bedding) and other flammable ob7ects are nearb". An escape route is ver" important) but successfull" escaping also depends on earl" recognition of a fire) which is assisted b" smo(e detectors.&'+% ,ognitive Level% ,omprehension-8nderstanding R.+% p. C6:T/P% ,lient Needs ,ategor"% !ealth Promotion and 5aintenance 0!ealth Promotion-&isease Prevention4 5$,% 'ntegrated Process% Teaching-Learning,op"right 9 6:1;) 6:1:) 6::b. =' will eventuall" be able to perform all m" former activities.>c. =5" goal is to achieve the highest level of functioning that ' can.>d. =+ull recover" from a ma7or burn in7ur" never occurs.>AN$% ,Although a return to preburn functional levels is rarel" possible) burned clients are considered full" recovered or rehabilitated when the" have achieved their highest possible level of ph"sical) social) and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning.&'+% ,ognitive Level% Application-Appl"ing or higher R.+% N-AT/P% ,lient Needs ,ategor"% Ph"siological 'ntegrit" 0Ph"siological Adaptation1'llness 5anagement4 5$,% 'ntegrated Process% Nursing Process 0.valuation4H. Which finding indicates to the nurse that a client understands the ps"chosocial impact of a severe burn in7ur"?a. ='t is normal to feel some depression.>b. =' will go bac( to wor( immediatel".>c. =' will not feel anger about m" situation.>d. =/nce ' get home) things will be normal.>AN$% A&uring the recover" period) and for some time after discharge from the hospital) clients with severe burn in7uries are li(el" to have ps"chological problems that re*uire intervention. &epression is one of these problems. Frief) loss) aniet") anger) fear) and guilt are all normal feelings that can occur. ,lients need to (now that problems of ph"sical care and ps"chological stresses ma" be overwhelming.,op"right 9 6:1;) 6:1:) 6::b. =Tagamet can help prevent h"povolemic shoc() which can be fatal.>c. =This will help prevent stomach ulcers) which are common after burns.>d. =This drug will help prevent (idne" damage caused b" deh"dration.>AN$% ,8lcerative gastrointestinal disease 0,urling#s ulcer4 ma" develop within 6@ hours after a severe burn as a result of increased h"drochloric acid production and a decreased mucosal barrier. This process occurs because of the s"mpathetic nervous s"stem stress response. ,imetidine inhibits the production and release of h"drochloric acid. ,imetidinedoes not affect intestinal movement and does not prevent h"povolemic shoc( or (idne" damage.&'+% ,ognitive Level% ,omprehension-8nderstanding R.+% p. C1GT/P% ,lient Needs ,ategor"% Ph"siological 'ntegrit" 0Pharmacological and Parenteral Therapies1.pected Actions-/utcomes4 5$,% 'ntegrated Process% Teaching-Learning1@. A client who is burned is drooling and is having difficult" swallowing. Which action doesthe nurse ta(e first?a. Assess level of consciousness and pupillar" reactions.b. Ascertain the time food or li*uid was last consumed.c. Auscultate breath sounds over the trachea and mainstem bronchi.d. 5easure abdominal girth and auscultate bowel sounds.,op"right 9 6:1;) 6:1:) 6::d. =When the burn wounds are closed.>AN$% &'ntact s(in is a ma7or barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn in7ur") the client remains at high ris( for infection as long as an" area of s(in is open.&'+% ,ognitive Level% ,omprehension-8nderstanding R.+% p. C16T/P% ,lient Needs ,ategor"% Ph"siological 'ntegrit" 0Reduction of Ris( Potential1Potential for Alterations in 3od" $"stems4 5$,% 'ntegrated Process% ,op"right 9 6:1;) 6:1:) 6::b. =+or a few da"s after surger") the donor sites will be painful.>c. =' will have some scarring in the area where the s(in is removed.>d. =' am still at ris( for infection after the procedure until the burn heals.>AN$% A+actors other than tissue t"pe) such as circulation and infection) influence whether and how well a graft will wor(. The client should be prepared for the possibilit" that not all grafting procedures will be successful. &onor sites will be painful after surger") scarring can occur in the area where s(in is removed for grafting) and the client is still at ris( for infection.&'+% ,ognitive Level% Application-Appl"ing or higher R.+% N-AT/P% ,lient Needs ,ategor"% Ph"siological 'ntegrit" 0Ph"siological Adaptation1'llness 5anagement4 5$,% 'ntegrated Process% Nursing Process 0.valuation4;1. Which intervention b" the nurse is most appropriate to reduce a client#s pain after a burn in7ur"?a. Administering morphine sulfate @ mg intravenousl"b. Administering morphine sulfate @ mg intramuscularl"c. Appl"ing ice to the burned area for 6: minutesd. Avoiding tactile stimulation near the burned areaAN$% A&rug therap" for pain management re*uires opioid and non2opioid analgesics. The 'K route is used because of problems with absorption from the muscle and the stomach. Tactile stimulation can be used for pain management. +or the client to avoid shivering) the room must be (ept warm) and ice should not be used. 'ce would decrease blood flow to the area.&'+% ,ognitive Level% Application-Appl"ing or higher R.+% N-AT/P% ,lient Needs ,ategor"% Ph"siological 'ntegrit" 0Pharmacological and Parenteral Therapies1.pected Actions-/utcomes45$,% 'ntegrated Process% Nursing Process 0'mplementation4;6. The nurse assesses a client in the burn unit after the client was repositioned b" the nursing assistant. The nurse intervenes after finding the client repositioned in what manner?a. $upine with one pillow behind the headb. $emi2+owler#s position with arms elevatedc. Wrists etended to ;: degrees in a splintd. A towel roll placed under the nec( or shoulder,op"right 9 6:1;) 6:1:) 6::