A client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement.

Which of these actions should the nurse take to effectively assist the patient?

Medicate the client 30 minutes before the procedure.

Reassure the client that the procedure is not painful.

Utilize meditation and imagery.

Administer pain medication around the clock.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Medicate the client 30 minutes before the procedure. This is the correct action. Administering pain medication 30 minutes before the procedure allows the medication to take effect and provides pain control during the procedure.
Choice B rationale
Reassure the client that the procedure is not painful. This is not accurate. Debridement and hydrotherapy can be painful, so it’s important to manage the client’s pain effectively.
Choice C rationale
Utilize meditation and imagery. While these techniques can be helpful adjuncts to pain management, they should not replace pharmacological pain management in this situation.
Choice D rationale
Administer pain medication around the clock. While it’s important to manage pain effectively, this does not specifically address the client’s needs during the hydrotherapy and debridement procedure.

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Correct Answer is C

Explanation

Choice A rationale
While pain at the burn site can be a symptom of many conditions, it is not a specific indicator of a local infection in the burned area.
Choice B rationale
Edematous hands can be a sign of many conditions, including burns, but they are not a specific indicator of a local infection in the burned area.
Choice C rationale
A foul odor from the burned area is a strong indicator of a local infection. Bacteria and other microorganisms that cause infections can produce waste products that have a foul smell.
Choice D rationale
A temperature of 99.8 degrees Fahrenheit is within the normal body temperature range and is not a specific indicator of a local infection in the burned area.

A. Inject the medication into the abdomen above the level of the iliac crest. B. Use a 1-inch needle to inject the medication. C. Use a 22-gauge needle to inject the medication. D. Massage the injection site after administration of the medication.

Correct Answer is A

Explanation

Choice A rationale
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
Choice B rationale
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
Choice C rationale
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
Choice D rationale
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.

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A client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement. Which of these actions should the nurse take to effectively assist the patient?

Nursing Test Bank

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A client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement.

Which of these actions should the nurse take to effectively assist the patient?