Priority nursing diagnoses for burns include: (Select All That Apply)

Adequate Tissue Perfusion

Risk for infection

Impaired Gas Exchange

Acute Pain

Fluid Volume Deficit

Answer and Explanation

Correct Answer : B,C,D,E

A. Adequate Tissue Perfusion
While this important in burn management, it is not typically classified as a priority nursing diagnosis in the early stages of treatment.

B. Risk for infection
Burned skin is a lost barrier to pathogens, increasing infection risk.

C. Impaired Gas Exchange
Especially in cases of inhalation injury, airway swelling or carbon monoxide exposure can impair gas exchange.

D. Acute Pain
Burns cause significant pain that requires management for comfort and healing.

E. Fluid Volume Deficit
Burns result in fluid shifts and capillary leakage, leading to hypovolemia.

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Correct Answer is D

Explanation

A. Timely administration of prophylactic antibiotics:
Helps reduce infection risk, not increase it.

B. Proper hand hygiene by healthcare providers:
Prevents infection; this is an important part of infection control.

C. Adequate wound cleaning and debridement:
Helps reduce bacterial load and supports healing.

D. Delayed wound closure and prolonged healing:
The longer the wound is open, the greater the risk of infection due to exposed tissue and compromised barrier function.

A. "Use a moisturizer on your skin after cleaning." B. "Rub your skin firmly when cleaning." C. "Wash your skin daily with hot water.” D. "Allow your skin to air dry after bathing.”

Correct Answer is A

Explanation

A. "Use a moisturizer on your skin after cleaning."
Moisturizers help maintain skin hydration and barrier function, reducing the risk of breakdown and infection.

B. "Rub your skin firmly when cleaning."
This can cause microabrasions and increase the risk of skin breakdown and infection.

C. "Wash your skin daily with hot water.”
Hot water can dry out the skin and compromise the skin barrier, increasing infection risk.

D. "Allow your skin to air dry after bathing.”
Patting the skin dry is better than air drying, which can lead to excessive dryness and irritation.

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Priority nursing diagnoses for burns include: (Select All That Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following factors increases the risk for infection in burn patients?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

The nurse in a high school clinic is aware of an unusually high incidences of cold sores among the student population. Which information from the nurse will be the most helpful in controlling the spread of the causative virus, HSV-1?

The nurse is explaining to a family the benefit of a patient-controlled analgesia pump. Which of the following is an appropriate use of Dilaudid PCA for burn patients?

Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

A nurse is preparing to administer liquid mycostatin 600,000 units PO every 8 hr. Available is mycostatin 100,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number.)

A nurse is assisting with the care of a client who sustained severe carbon monoxide (CO) poisoning after being trapped in a burning building. Which of the following actions should the nurse take first?

A nurse is collecting data from a client who sustained superficial partial-thickness and deep partial burns 72 hours ago. Which of the following findings should the nurse report to the provider?

When prioritizing the care of a client with burns, which intervention should the nurse implement first?