The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintains to retain maximum function of this joint?
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Solution
Hip at zero flexion with leg flat
Option D: Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree of flexion.
The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?
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Solution
Have the client turn the head from side to side 90 degrees every hour while awake.
Option C: The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion.
In reviewing the burned client’s laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis?
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Solution
The “bands” outnumber the “segs.”
Option C: Normally, the mature segmented neutrophils (“segs”) are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood count. Fewer than 3% to 5% of the circulating white blood cells should be the less mature “band” neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. Such a shift indicates severe infection or sepsis, in which the client’s immune system cannot keep pace with the infectious process.
Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?
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Solution
Handwashing on entering the client’s room
Option A: Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Although all the interventions listed above can help reduce the risk for infection, only hand washing can prevent cross contamination.
The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?
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Solution
Auscultate breath sounds over the trachea and mainstem bronchi.
Option C: Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client’s airway is in severe jeopardy and intubation is highly likely to be needed shortly.
The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?
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Solution
Myocardial infarction 1 year ago
Option C: It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation.
The burned client’s family ask at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?
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Solution
“When the burn wounds are closed.”
Option B: Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open.
Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?
Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?
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Solution
The client’s oxygen saturation is 97%.
Option C: Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.
In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?
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Solution
“In what exact place or space were you when you were burned?”
Option D: The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms. although smoking increases the risk for some problems, it does not predispose the client for an inhalation injury.