The nurse assesses the hand of a client who has a thermal burn.
Which actions should the nurse include in the plan of care? Select all that apply.

Insert gauze between each of the fingers.

Apply vitamin E lotion to keep hand moist.

Cover the burn with silver sulfadiazine cream.

Pierce small blisters before dressing the hand.

Give morphine sulfate before burn care.

Maintain strict sterile technique.

Answer and Explanation

Correct Answer : A,C,E,F

The scenario requires applying principles of wound management, pain control, and infection prevention for thermal burns. Knowledge of tissue integrity, pharmacological intervention, and sterile surgical asepsis is necessary to prevent complications like syndactyly, infection, and severe pain during treatment.

Choice A rationale

Placing gauze between digits prevents skin surfaces from touching during healing. This essential intervention stops webbing or contractures, known as syndactyly, by maintaining anatomical separation of the fingers while absorbing exudate from the injured thermal burn sites.

Choice B rationale

Topical lotions containing vitamin E are inappropriate for acute thermal burns. Lotions can trap heat or introduce contaminants into open wounds. Specialized antimicrobial agents are required instead of over the counter moisturizers to ensure proper healing and safety.

Choice C rationale

Silver sulfadiazine is a broad spectrum topical antimicrobial used to prevent and treat wound sepsis in second and third degree burns. It effectively penetrates the eschar to reduce bacterial colonization, which is critical for successful skin regeneration.

Choice D rationale

Intact blisters serve as a natural sterile barrier against environment pathogens. Piercing or debriding small blisters increases the risk of infection and tissue trauma. Blisters should remain intact unless they interfere with joint movement or are significantly large.

Choice E rationale

Burn care and debridement are excruciatingly painful procedures. Administering systemic analgesics like morphine sulfate prior to care ensures the client reaches a therapeutic peak, which facilitates cooperation, reduces physiological stress, and manages severe pain during dressing changes.

Choice F rationale

Thermal burns destroy the primary skin barrier, leaving the client highly susceptible to healthcare associated infections. Strict sterile technique during wound care and dressing changes is mandatory to prevent sepsis and promote uncomplicated healing of the damaged tissues.

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Free Nursing Study Resources

Correct Answer is ["167"]

Explanation

Step 1 is 2 L × 1,000 mL = 2,000 mL.

Step 2 is 2,000 mL ÷ 12 hours = 166.666 mL/hr.

Step 3 is round 166.666 to 167 mL/hr. Final calculated answer is 167.

A. Ambulate twice daily. B. Pantoprazole 80 mg IV bolus twice daily. C. Pancrelipase 500 units/kg PO three times daily with meals. D. Initiate a low-residue diet.

Correct Answer is B

Explanation

Acute pancreatitis involves the autodigestion of the pancreas by activated enzymes. Knowledge of systemic inflammatory response and gastric acid management is necessary to understand the rationale for bowel rest and the prevention of secondary complications like stress ulcers.

Choice A rationale

Early ambulation is generally encouraged but not a priority during the acute, painful phase of pancreatitis. The client often requires bed rest to decrease metabolic demands and minimize the stimulation of pancreatic enzyme secretion and activity.

Choice B rationale

Pantoprazole is a proton pump inhibitor used to decrease gastric acid secretion. In pancreatitis, reducing acid prevents it from entering the duodenum and stimulating the release of secretin, which would otherwise trigger further pancreatic enzyme production.

Choice C rationale

Pancrelipase consists of digestive enzymes meant for chronic pancreatitis or pancreatic insufficiency. In acute pancreatitis, giving enzymes orally would further stimulate the inflamed organ and worsen the condition; the client must remain nothing by mouth.

Choice D rationale

A low-residue diet is inappropriate for acute pancreatitis. The initial treatment must be strict bowel rest (NPO) to stop all stimulus to the pancreas, allowing the inflammation to subside before reintroducing any oral intake or nutrients..

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The nurse assesses the hand of a client who has a thermal burn. Which actions should the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["167"]

Explanation

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

Correct Answer is B

Explanation

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The nurse assesses the hand of a client who has a thermal burn. Which actions should the nurse include in the plan of care? Select all that apply.

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The nurse completes teaching the client with a deep partial thickness burn about silver sulfadiazine. Which client statements indicate that the teaching was effective? Select all that apply.

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The nurse assesses the hand of a client who has a thermal burn.
Which actions should the nurse include in the plan of care? Select all that apply.