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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Correct Answer is C

Explanation

A. Deep partial thickness:
Involves blistering and damage to the dermis, which is more severe than sunburn.

B. Superficial partial thickness:
Involves blistering, typical of scalds or more intense burns-not most sunburns.

C. Superficial thickness:
Severe sunburn affects only the epidermis, with redness, pain, and no blistering-this is superficial.

D. Full thickness:
Involves entire skin layers and sometimes muscle, which is not consistent with sunburn.

A. Percent of body surface burned B. Respiratory status C. Review of chronic illnesses D. Burn depth

Correct Answer is B

Explanation

A. Percent of body surface burned:
Important for guiding fluid resuscitation, but airway and breathing always take priority in the ABCs.

B. Respiratory status:
Inhalation injury is a life-threatening complication in fire-related burns. Assess for stridor, soot in nares/mouth, and signs of respiratory distress first.

C. Review of chronic illnesses:
Relevant for overall care planning, but not an initial priority in the emergency phase.

D. Burn depth:
Guides long-term care but is secondary to airway and breathing in the acute setting.

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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.

Nursing Test Bank

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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.