A nurse is providing care for a client with severe burns.

The client’s vital signs at 0820 are as follows: Blood pressure 140/80 mm Hg, Heart rate 110/min, Respiratory rate 25/min, Sa 98% on room air, Temperature 36.1 C (97° F). Which of the following interventions should the nurse consider? (Select all that apply.)

Choice A rationale
While it’s true that electrical burns can cause more skin damage than what can be seen on the skin, this statement does not fully address the client’s misconception about the severity of their burn.
Choice B rationale
This is the best response because it directly addresses the client’s misconception and provides accurate information. Electrical burns can indeed have small amounts of skin damage but cause more extensive damage beneath the skin. This is because the electrical current can pass through the body and damage internal tissues and organs, even if the visible wound on the skin is small.
Choice C rationale
While electrical burns can cause reddened or purplish skin, they do not typically cause blistering. Furthermore, this statement does not address the client’s misconception about the severity of their burn.
Choice D rationale
This statement is incorrect. Electrical burns are not typically minor. They can cause serious internal injuries and complications, even if the visible wound on the skin is small.

Choice A rationale
At the time the client takes a proton-pump inhibitor. Sucralfate and proton pump inhibitors should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
Choice B rationale
At the time the client takes an antacid. Sucralfate and antacids should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
Choice C rationale
One hour before breakfast and the evening meal. This is the correct answer. Sucralfate is most effective when taken on an empty stomach. Taking it one hour before meals allows it to form a protective coating on the ulcer before food is introduced into the stomach.
Choice D rationale
Thirty minutes after breakfast and the evening meal. Sucralfate should not be taken immediately after meals. It is most effective when taken on an empty stomach.