After assessing an older adult client with a burn wound, the ...

[bucstennis@aim.com]

After 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.

Question 2

A nurse reviews the following data in the chart of a client with burn injuries:
 
  Admission Notes
  Wound Assessment
  36-year-old female with bilateral leg burns
  NKDA
  Health history of asthma and seasonal allergies
  Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10.
  Based on the data provided, how should the nurse categorize this client's injuries?
  a.
  Partial-thickness deep
  b.
  Partial-thickness superficial
  c.
  Full thickness
  d.
  Superficial

[kalskdjl1212]

Answer to Question 1

ANS: C
Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the client's skin should all be implemented but these actions do not take priority over determining whether the client has an infection.

Answer to Question 2

ANS: C
The characteristics of the client's wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

[bucstennis@aim.com]

TYSM

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Gracias!