A nurse is assisting in the care of a client who has severe burns.

Exhibits

Which of the following actions should the nurse take when caring for a client who has severe burns to the lower extremities? Select all that apply.

Cool the burn with ice water.

Administer opioid analgesics.

Administer systemic antibiotics.

Keep extremities elevated.

Remove all sheets and coverings.

Answer and Explanation

Correct Answer : B,C,D

A. Cool the burn with ice water:
Never use ice on burns. It can cause vasoconstriction and worsen tissue injury.

B. Administer opioid analgesics:
Severe pain is common in burn injuries. IV opioids are preferred for rapid onset and titration.

C. Administer systemic antibiotics:
Burn injuries compromise the skin barrier, increasing the risk of infection. Systemic antibiotics may be necessary to prevent or treat infections.

D. Keep extremities elevated:
Elevating extremities helps reduce edema and improve venous return.

E. Remove all sheets and coverings:
Sheets may provide warmth and protection. Removing them indiscriminately may worsen hypothermia or cause further trauma to the skin.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. “Wash linens, clothes and towels.”
Scabies mites can survive for up to 2–3 days on fabrics. Washing items in hot water and drying on high heat effectively kills mites.

B. “Dry clean all linens, towels, and clothes.”
Not necessary; washing with hot water is sufficient and more accessible.

C. “Remove infested pets from the home.”
Scabies is species-specific. Human scabies mites do not live on pets.

D. “Discard infested mattresses.”
Mites cannot survive long on surfaces without human contact. Mattresses can be vacuumed and covered if needed.

A. Minimal edema in the affected extremities B. Temperature of 39.1 C (102.4 F) C. Pain at the burn sites D. urine output of 30 ml/hr

Correct Answer is B

Explanation

A. Minimal edema in the affected extremities:
Expected after 72 hours as inflammation begins to subside.

B. Temperature of 39.1°C (102.4°F):
Elevated temperature may indicate infection or systemic inflammation and should be reported.

C. Pain at the burn sites:
Pain is expected, especially in partial-thickness burns where nerve endings are exposed.

D. Urine output of 30 mL/hr:
While on the lower end of normal, this is still acceptable for an adult (minimum: 30 mL/hr).

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A nurse is assisting in the care of a client who has severe burns. Exhibits Which of the following actions should the nurse take when caring for a client who has severe burns to the lower extremities? Select all that apply.

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A nurse is assisting in the care of a client who has severe burns.

Exhibits

Which of the following actions should the nurse take when caring for a client who has severe burns to the lower extremities? Select all that apply.