Chapter 26
1. The registered nurse assigns a client who has an open burn
wound to a licensed practical nurse (LPN). Which instruction should
the nurse provide to the LPN when assigning this client?
a. Administer the prescribed tetanus toxoid vaccine.
b. Assess the clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients room.
ANS: D
Infection can occur when microorganisms from another person or
from the environment are transferred to the client. Although all of
the interventions listed can help reduce the risk for infection,
handwashing is the most effective technique for preventing infection
transmission.
DIF: Applying/Application REF: 466
KEY: Infection control| Standard Precautions| collaboration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
2. The nurse is caring for a client with an acute burn injury. Which
action should the nurse take to prevent infection by
autocontamination?
a. Use a disposable blood pressure cuff to avoid sharing with other clie
b. Change gloves between wound care on different parts of the clients
c. Use the closed method of burn wound management for all wound ca
d. Advocate for proper and consistent handwashing by all members of
ANS: B
Autocontamination is the transfer of microorganisms from one area
to another area of the same clients body, causing infection of a
previously uninfected area. Although all techniques listed can help
reduce the risk for infection, only changing gloves between
performing wound care on different parts of the clients body can
prevent autocontamination.
DIF: Applying/Application REF: 485
KEY: Infection control| Standard Precautions
MSC: Integrated Process: Nursing Process: Implementation
,NOT: Client Needs Category: Safe and Effective Care Environment:
Safety and Infection Control
3. The nurse teaches burn prevention to a community group. Which
statement by a member of the group should cause the nurse the
greatest concern?
a. I get my chimney swept every other year.
b. My hot water heater is set at 120 degrees.
c. Sometimes I wake up at night and smoke.
d. I use a space heater when it gets below zero.
ANS: C
House fires are a common occurrence and often lead to serious
injury or death. The nurse should be most concerned about a person
who wakes up at night and smokes. The nurse needs to question this
person about whether he or she gets out of bed to do so, or if this
person stays in bed, which could lead to falling back asleep with a
lighted cigarette. Although it is recommended to have chimneys
swept every year, skipping a year does not pose as much danger as
smoking in bed, particularly if the person does not burn wood
frequently. Water heaters should be set below 140 F. Space heaters
should be used with caution, and the nurse may want to ensure that
the person does not allow it to get near clothing or bedding.
DIF: Applying/Application REF: 472
KEY: Safety| smoking cessation MSC: Integrated Process:
Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
4. A nurse cares for a client who has facial burns. The client asks,
Will I ever look the same? How should the nurse respond?
a. With reconstructive surgery, you can look the same.
b. We can remove the scars with the use of a pressure dressing.
c. You will not look exactly the same but cosmetic surgery will help.
d. You shouldnt start worrying about your appearance right now.
ANS: C
Many clients have unrealistic expectations of reconstructive surgery
and envision an appearance identical or equal in quality to the
preburn state. The nurse should provide accurate information that
includes something to hope for. Pressure dressings prevent further
scarring; they cannot remove scars. The client and the family should
be taught the expected cosmetic outcomes.
, DIF: Applying/Application REF: 488
KEY: Psychosocial response| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
5. A nurse assesses a client who has a burn injury. Which statement
indicates the client has a positive perspective of his or her
appearance?
a. I will allow my spouse to change my dressings.
b. I want to have surgical reconstruction.
c. I will bathe and dress before breakfast.
d. I have secured the pressure dressings as ordered.
ANS: C
Indicators that the client with a burn injury has a positive perception
of his or her appearance include a willingness to touch the affected
body part. Self-care activities such as morning care foster feelings of
self-worth, which are closely linked to body image. Allowing others
to change the dressing and discussing future reconstruction would
not indicate a positive perception of appearance. Wearing the
dressing will assist in decreasing complications but will not enhance
self-perception.
DIF: Applying/Application REF: 488
KEY: Psychosocial response| coping
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Psychosocial Integrity
6. The nurse assesses a client who has a severe burn injury. Which
statement indicates the client understands the psychosocial impact
of a severe burn injury?
a. It is normal to feel some depression.
b. I will go back to work immediately.
c. I will not feel anger about my situation.
d. Once I get home, things will be normal.
ANS: A
During the recovery period, and for some time after discharge from
the hospital, clients with severe burn injuries are likely to have
psychological problems that require intervention. Depression is one
of these problems. Grief, loss, anxiety, anger, fear, and guilt are all
normal feelings that can occur. Clients need to know that problems
of physical care and psychological stresses may be overwhelming.
1. The registered nurse assigns a client who has an open burn
wound to a licensed practical nurse (LPN). Which instruction should
the nurse provide to the LPN when assigning this client?
a. Administer the prescribed tetanus toxoid vaccine.
b. Assess the clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients room.
ANS: D
Infection can occur when microorganisms from another person or
from the environment are transferred to the client. Although all of
the interventions listed can help reduce the risk for infection,
handwashing is the most effective technique for preventing infection
transmission.
DIF: Applying/Application REF: 466
KEY: Infection control| Standard Precautions| collaboration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
2. The nurse is caring for a client with an acute burn injury. Which
action should the nurse take to prevent infection by
autocontamination?
a. Use a disposable blood pressure cuff to avoid sharing with other clie
b. Change gloves between wound care on different parts of the clients
c. Use the closed method of burn wound management for all wound ca
d. Advocate for proper and consistent handwashing by all members of
ANS: B
Autocontamination is the transfer of microorganisms from one area
to another area of the same clients body, causing infection of a
previously uninfected area. Although all techniques listed can help
reduce the risk for infection, only changing gloves between
performing wound care on different parts of the clients body can
prevent autocontamination.
DIF: Applying/Application REF: 485
KEY: Infection control| Standard Precautions
MSC: Integrated Process: Nursing Process: Implementation
,NOT: Client Needs Category: Safe and Effective Care Environment:
Safety and Infection Control
3. The nurse teaches burn prevention to a community group. Which
statement by a member of the group should cause the nurse the
greatest concern?
a. I get my chimney swept every other year.
b. My hot water heater is set at 120 degrees.
c. Sometimes I wake up at night and smoke.
d. I use a space heater when it gets below zero.
ANS: C
House fires are a common occurrence and often lead to serious
injury or death. The nurse should be most concerned about a person
who wakes up at night and smokes. The nurse needs to question this
person about whether he or she gets out of bed to do so, or if this
person stays in bed, which could lead to falling back asleep with a
lighted cigarette. Although it is recommended to have chimneys
swept every year, skipping a year does not pose as much danger as
smoking in bed, particularly if the person does not burn wood
frequently. Water heaters should be set below 140 F. Space heaters
should be used with caution, and the nurse may want to ensure that
the person does not allow it to get near clothing or bedding.
DIF: Applying/Application REF: 472
KEY: Safety| smoking cessation MSC: Integrated Process:
Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
4. A nurse cares for a client who has facial burns. The client asks,
Will I ever look the same? How should the nurse respond?
a. With reconstructive surgery, you can look the same.
b. We can remove the scars with the use of a pressure dressing.
c. You will not look exactly the same but cosmetic surgery will help.
d. You shouldnt start worrying about your appearance right now.
ANS: C
Many clients have unrealistic expectations of reconstructive surgery
and envision an appearance identical or equal in quality to the
preburn state. The nurse should provide accurate information that
includes something to hope for. Pressure dressings prevent further
scarring; they cannot remove scars. The client and the family should
be taught the expected cosmetic outcomes.
, DIF: Applying/Application REF: 488
KEY: Psychosocial response| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
5. A nurse assesses a client who has a burn injury. Which statement
indicates the client has a positive perspective of his or her
appearance?
a. I will allow my spouse to change my dressings.
b. I want to have surgical reconstruction.
c. I will bathe and dress before breakfast.
d. I have secured the pressure dressings as ordered.
ANS: C
Indicators that the client with a burn injury has a positive perception
of his or her appearance include a willingness to touch the affected
body part. Self-care activities such as morning care foster feelings of
self-worth, which are closely linked to body image. Allowing others
to change the dressing and discussing future reconstruction would
not indicate a positive perception of appearance. Wearing the
dressing will assist in decreasing complications but will not enhance
self-perception.
DIF: Applying/Application REF: 488
KEY: Psychosocial response| coping
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Psychosocial Integrity
6. The nurse assesses a client who has a severe burn injury. Which
statement indicates the client understands the psychosocial impact
of a severe burn injury?
a. It is normal to feel some depression.
b. I will go back to work immediately.
c. I will not feel anger about my situation.
d. Once I get home, things will be normal.
ANS: A
During the recovery period, and for some time after discharge from
the hospital, clients with severe burn injuries are likely to have
psychological problems that require intervention. Depression is one
of these problems. Grief, loss, anxiety, anger, fear, and guilt are all
normal feelings that can occur. Clients need to know that problems
of physical care and psychological stresses may be overwhelming.
