A client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement.

Which of these actions should the nurse take to effectively assist the patient?

Medicate the client 30 minutes before the procedure.

Reassure the client that the procedure is not painful.

Utilize meditation and imagery.

Administer pain medication around the clock.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Medicate the client 30 minutes before the procedure. This is the correct action. Administering pain medication 30 minutes before the procedure allows the medication to take effect and provides pain control during the procedure.
Choice B rationale
Reassure the client that the procedure is not painful. This is not accurate. Debridement and hydrotherapy can be painful, so it’s important to manage the client’s pain effectively.
Choice C rationale
Utilize meditation and imagery. While these techniques can be helpful adjuncts to pain management, they should not replace pharmacological pain management in this situation.
Choice D rationale
Administer pain medication around the clock. While it’s important to manage pain effectively, this does not specifically address the client’s needs during the hydrotherapy and debridement procedure.

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Correct Answer is B

Explanation

Choice A rationale
Changing the ostomy pouch daily is not necessary and can lead to skin irritation. The pouch should be changed every 2-4 days or as directed by the healthcare provider.
Choice B rationale
The ostomy pouch should be emptied when it is 1/3 to 1/2 full to prevent leakage and skin irritation.
Choice C rationale
Trimming the opening of the ostomy seal to be 1/2 in. wider than the stoma is incorrect. The opening should be just slightly larger than the stoma to prevent skin irritation.
Choice D rationale
Applying lotion to the peristomal skin when changing the ostomy pouch is not recommended as it can interfere with the adhesion of the pouch.

A. Place the patient in the Trendelenburg position. B. Change the patient’s position slowly. C. Reduce the oxygen flow. D. Increase the IV fluid flow.

Correct Answer is B

Explanation

Choice A rationale
The Trendelenburg position, which involves laying the patient flat on their back with their legs elevated higher than their head, is not recommended for patients with septic shock. This position can increase intracranial pressure and does not improve circulation or oxygenation.
Choice B rationale
Changing the patient’s position slowly is important in managing an elderly patient with septic shock. Rapid changes in position can cause a drop in blood pressure (orthostatic hypotension), which can lead to falls or decreased perfusion to vital organs.
Choice C rationale
Reducing the oxygen flow is not recommended for patients with septic shock. These patients often have difficulty with oxygenation and may require supplemental oxygen to maintain adequate oxygen levels.
Choice D rationale
Increasing the IV fluid flow is part of the initial management of septic shock to restore perfusion, but it should be done based on careful assessment and monitoring of the patient’s response to fluids. Overzealous fluid resuscitation can lead to fluid overload and complications such as pulmonary edema.

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A client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement. Which of these actions should the nurse take to effectively assist the patient?

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A client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement.

Which of these actions should the nurse take to effectively assist the patient?