Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
60. A nurse is caring for a client with second-degree burns of both arms. Which care need will be more challenging because of the location of the burn?
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
60. A nurse is caring for a client with second-degree burns of both arms. Which care need will be more challenging because of the location of the burn?
. Reducing risk for immunosuppression and infection.
. Reducing potential for contractures and deformity.
. Establishing IV access for administration of fluids.
. Assessment of vital signs, including blood pressure.
Test-Taking Tip
Visualize the burn location and how treating the wound would interfere with the care need.
Content Area: Adult Health, Integumentary; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
.
Answer 1 is incorrect because infection is not a greater concern. Answer 2 is correct because burn wound tissue shortens because of flexion of muscles in wound healing. Contractures will need to be prevented with splints or traction. Answer 3 is incorrect because large-bore central line IV catheters via cutdown can be placed in any major vessel. Answer 4 is incorrect because a sterile dressing can be applied under the BP cuff, or a Doppler can be used, or an arterial catheter can be inserted.