A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)
a. Music as a distraction
b. Tactile stimulation
c. Massage to injury sites
d. Cold compresses
e. Increasing client control
Question 2A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.)
a. Provide at least 5000 kcal/day.
b. Start an oral diet on the first day.
c. Administer a diet high in protein.
d. Collaborate with a registered dietitian.
e. Offer frequent high-calorie snacks.
Question 3A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.)
a. Administer analgesics.
b. Prevent wound infections.
c. Provide fluid replacement.
d. Decrease core temperature.
e. Initiate physical therapy.
Question 4After assessing an older adult client with a burn wound, the nurse documents the findings as follows:
Vital Signs
Laboratory Results
Wound Assessment
Heart rate: 110 beats/min
Blood pressure: 112/68 mm Hg
Respiratory rate: 20 breaths/min
Oxygen saturation: 94
Pain: 3/10
Red blood cell count: 5,000,000/mm3
White blood cell count: 10,000/mm3
Platelet count: 200,000/mm3
Left chest burn wound, 3 cm 2.5 cm 0.5 cm, wound bed pale, surrounding tissues with edema present
Based on the documented data, which action should the nurse take next?
a.
Assess the client's skin for signs of adequate perfusion.
b.
Calculate intake and output ratio for the last 24 hours.
c.
Prepare to obtain blood and wound cultures.
d.
Place the client in an isolation room.
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