A nurse is caring for a client who has severe burns.

Exhibits
Which of the following actions should the nurse take when caring for a client with severe burns?
Select all that apply.

Cool the burn with ice water.

Administer opioid analgesics.

Administer systemic antibiotics.

Administer benzodiazepines for anxiety management.

Lay the head of the bed flat.

Answer and Explanation

Correct Answer : B,D

A. Cool the burn with ice water: Cooling with ice water is contraindicated as it can cause vasoconstriction and worsen tissue damage. Cool saline or tepid water is preferred for immediate care.

B. Administer opioid analgesics: Severe burns are excruciatingly painful, and opioid analgesics are appropriate for managing the pain.

C. Administer systemic antibiotics: Systemic antibiotics are not routinely administered unless there are signs of infection or sepsis.

D. Administer benzodiazepines for anxiety management: Anxiety can exacerbate the client’s distress, and benzodiazepines are effective in reducing anxiety.

E. Lay the head of the bed flat: This is inappropriate; the client’s airway must remain patent, and raising the head of the bed can help reduce respiratory distress.

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Correct Answer is A

Explanation

A. Muffled heart sounds: Muffled heart sounds are a hallmark finding in cardiac tamponade due to fluid accumulation in the pericardial sac, which dampens the sound of the heart.

B. Flattened neck veins: Flattened neck veins are inconsistent with cardiac tamponade. Instead, distended neck veins are commonly seen due to impaired venous return to the heart.

C. Bradycardia: Tachycardia, rather than bradycardia, is more likely as a compensatory response to maintain cardiac output.

D. Sudden lethargy: While lethargy may occur as a late sign of decreased cardiac output, it is not specific to cardiac tamponade.

A. Prepare for a STAT non-contrast CT scan B. Perform a thorough health history C. Insert an indwelling urinary catheter to monitor urine output D. Administer acetaminophen by mouth for pain control

Correct Answer is A

Explanation

A. Prepare for a STAT non-contrast CT scan: After a traumatic fall, a non-contrast CT scan is critical to assess for internal injuries such as brain hemorrhage or spinal trauma.

B. Perform a thorough health history: History is essential but secondary to identifying life-threatening conditions.

C. Insert an indwelling urinary catheter: This is appropriate for monitoring output but not a priority before imaging.

D. Administer acetaminophen by mouth for pain control: Pain management is secondary to identifying life-threatening injuries.

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A nurse is caring for a client who has severe burns. Exhibits Which of the following actions should the nurse take when caring for a client with severe burns? Select all that apply.

Nursing Test Bank

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A nurse is caring for a client who has severe burns.

Exhibits
Which of the following actions should the nurse take when caring for a client with severe burns?
Select all that apply.