Nursing Care For Burns

Interventions for Clients with Burns
MULTIPLE CHOICE
1. The newly admitted client has burns on both legs. The burned areas
appear white and leather-like. No blisters or bleeding are present, and the client
states that he or she has little pain. How should this injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
ANS: A
The characteristics of the wound meet the criteria for a full-thickness injury
(color that is black, brown, yellow, white or red; no blisters; pain minimal;
outer layer firm and inelastic).
DIF: Cognitive Level: Application or higher

TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological
Integrity;
2. The newly admitted client has a large burned area on the right arm. The
burned area appears red, has blisters, and is very painful. How should this injury
be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
ANS: B
The characteristics of the wound meet the criteria for a superficial partial-
thickness injury (color that is pink or red; blisters; pain present and high).

Integrity;
3. The burned client newly arrived from an accident scene is prescribed to

receive 4 mg of morphine sulfate by IV push. What is the most important reason to
administer the opioid analgesic to this client by the intravenous route?
A. The medication will be effective more quickly than if given intramuscularly.
B. It is less likely to interfere with the client’s breathing and oxygenation.
C. The danger of an overdose during fluid remobilization is reduced.
D. The client delayed gastric emptying.
ANS: C
Although providing some pain relief has a high priority, and giving the drug by
the IV route instead of IM, SC, or orally does increase the rate of effect, the
most important reason is to prevent an overdose from accumulation of drug in the
interstitial space during the fluid shift of the emergent phase. When edema is
present, cumulative doses are rapidly absorbed when the fluid shift is resolving.
This delayed absorption can result in lethal blood levels of analgesics.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;
4. Which vitamin deficiency is most likely to be a long-term consequence

of a full-thickness burn injury?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
ANS: D
Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the
activation of vitamin D. Activation of vitamin D is lost completely in full-
thickness burns.
DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A

MSC: Client Needs Category: Health Promotion and Maintenance
5. Which client factors should alert the nurse to potential increased

complications with a burn injury?
A. The client is a 26-year-old male.
B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the client's clothing.
ANS: C
Burns of the perineum increase the risk for sepsis. Burns of the hands require
special attention to ensure the best functional outcome.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment

MSC: Client Needs Category: Physiological Integrity/Safe, Effective Care
Environment;
6. The burned client is ordered to receive intravenous cimetidine, an H2

histamine blocking agent, during the emergent phase. When the client's family asks
why this drug is being given, what is the nurse’s best response?
A. “To increase the urine output and prevent kidney damage.”
B. “To stimulate intestinal movement and prevent abdominal bloating.”
C. “To decrease hydrochloric acid production in the stomach and prevent
ulcers.”
D. “To inhibit loss of fluid from the circulatory system and prevent
hypovolemic shock.”
ANS: C
Ulcerative gastrointestinal disease may develop within 24 hours after a severe
burn as a result of increased hydrochloric acid production and decreased mucosal
barrier. Cimetidine inhibits the production and release of hydrochloric acid.

MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and
Maintenance;
7. At what point after a burn injury should the nurse be most alert for
the complication of hypokalemia?
A. Immediately following the injury
B. During the fluid shift
C. During fluid remobilization
D. During the late acute phase
ANS: C
Hypokalemia is most likely to occur during the fluid remobilization period as a
result of dilution, potassium movement back into the cells, and increased
potassium excreted into the urine with the greatly increased urine output.

8. What clinical manifestation should alert the nurse to possible carbon

monoxide poisoning in a client who experienced a burn injury during a house fire?
A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum
ANS: C
The saturation of hemoglobin molecules with carbon monoxide and the subsequent
vasodilation induces a “cherry red” color of the mucous membranes in these
clients. The other manifestations are associated with inhalation injury, but not
specifically carbon monoxide poisoning.

Integrity;
9. What clinical manifestation indicates that an escharotomy is needed on

a circumferential extremity burn?
A. The burn is full thickness rather than partial thickness.
B. The client is unable to fully pronate and supinate the extremity.
C. Capillary refill is slow in the digits and the distal pulse is absent.
D. The client cannot distinguish the sensation of sharp versus dull in the
extremity.
ANS: C
Circumferential eschar can act as a tourniquet when edema forms from the fluid
shift, increasing tissue pressure and preventing blood flow to the distal
extremities and increasing the risk for tissue necrosis. This problem is an
emergency and, without intervention, can lead to loss of the distal limb. This
problem can be reduced or corrected with an escharotomy.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Evaluation

10. What additional laboratory test should be performed on any African

American client who sustains a serious burn injury?
A. Total protein
B. Tissue type antigens
C. Prostate specific antigen
D. Hemoglobin S electrophoresis
ANS: D
Sickle cell disease and sickle cell trait are more common among African Americans.
Although clients with sickle cell disease usually know their status, the client
with sickle cell trait may not. The fluid, circulatory, and respiratory
alterations that occur in the emergent phase of a burn injury could result in
decreased tissue perfusion that is sufficient to cause sickling of cells, even in
a person who only has the trait. Determining the client’s sickle cell status by
checking the percentage of hemoglobin S is essential for any African American
client who has a burn injury.

Maintenance;
11. Which type of fluid should the nurse expect to prepare and administer
as fluid resuscitation during the emergent phase of burn recovery?
A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells
ANS: B
Although not universally true, most fluid resuscitation for burn injuries starts
with crystalloid solutions, such as normal saline and Ringer’s lactate. The burn
client rarely requires blood during the emergent phase unless the burn is
complicated by another injury that involved hemorrhage. Colloids and plasma are
not generally used during the fluid shift phase because these large particles pass
through the leaky capillaries into the interstitial fluid, where they increase the
osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen
the capillary leak syndrome and make maintaining the circulating fluid volume even
more difficult.

12. The client with a dressing covering the neck is experiencing some
respiratory difficulty. What is the nurse’s best first action?
A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.
ANS: B
Respiratory difficulty can arise from external pressure. The first action in this
situation would be to loosen the dressing and then reassess the client's
respiratory status.

Integrity;
13. The client who experienced an inhalation injury 6 hours ago has been
wheezing. When the client is assessed, wheezes are no longer heard. What is the
nurse’s best action?
A. Raise the head of the bed.
B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.
ANS: B
Clients with severe inhalation injuries may sustain such progressive obstruction
that they may lose effective movement of air. When this occurs, wheezing is no
longer heard and neither are breath sounds. The client requires the establishment
of an emergency airway and the swelling usually precludes intubation.

14. Ten hours after the client with 50% burns is admitted, her blood
glucose level is 90 mg/dL. What is the nurse’s best action?
A. Notify the emergency team.
B. Document the finding as the only action.
C. Ask the client if anyone in her family has diabetes mellitus.
D. Slow the intravenous infusion of dextrose 5% in Ringer's lactate.
ANS: B
Neural and hormonal compensation to the stress of the burn injury in the emergent
phase increases liver glucose production and release. An acute rise in the blood
glucose level is an expected client response and is helpful in the generation of
energy needed for the increased metabolism that accompanies this trauma.

15. On admission to the emergency department the burned client's blood

pressure is 90/60, with an apical pulse rate of 122. These findings are an
expected result of what thermal injury–related response?
A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning
ANS: A
Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage is
unusual in a burn injury. The physiologic effect of histamine release in injured
tissues is a loss of vascular volume to the interstitial space, with a resulting
decrease in blood pressure.

MSC: Client Needs Category: Physiological Integrity/Safe, Effective Care
Environment;
16. Twelve hours after the client was initially burned, bowel sounds are
absent in all four abdominal quadrants. What is the nurse’s best action?
A. Reposition the client onto the right side.
B. Document the finding as the only action.
C. Notify the emergency team.
D. Increase the IV flow rate.
ANS: B
Decreased or absent peristalsis is an expected response during the emergent phase
of burn injury as a result of neural and hormonal compensation to the stress of
injury. No currently accepted intervention changes this response, and it is not
the highest priority of care at this time.

Integrity;
17. Which clinical manifestation indicates that the burned client is moving
into the fluid remobilization phase of recovery?
A. Increased urine output, decreased urine specific gravity
B. Increased peripheral edema, decreased blood pressure
C. Decreased peripheral pulses, slow capillary refill
D. Decreased serum sodium level, increased hematocrit
ANS: A
The “fluid remobilization” phase improves renal blood flow, increasing diuresis
and restoring fluid and electrolyte levels. The increased water content of the
urine reduces its specific gravity.

TOP: Nursing Process Step: Evaluation
Integrity;
18. What is the priority nursing diagnosis during the first 24 hours for a
client with full-thickness chemical burns on the anterior neck, chest, and all
surfaces of the left arm?
A. Risk for Ineffective Breathing Pattern
B. Decreased Tissue Perfusion
C. Risk for Disuse Syndrome
D. Disturbed Body Image
ANS: C
During the emergent phase, fluid shifts into interstitial tissue in burned areas.
When the burn is circumferential on an extremity, the swelling can compress blood
vessels to such an extent that circulation is impaired distal to the injury,
necessitating the intervention of an escharotomy. Chemical burns do not cause
inhalation injury.

TOP: Nursing Process Step: Analysis
19. All of the following laboratory test results on a burned client's blood
are present during the emergent phase. Which result should the nurse report to the
physician immediately?
A. Serum sodium elevated to 131 mmol/L (mEq/L)
B. Serum potassium 7.5 mmol/L (mEq/L)
C. Arterial pH is 7.32
D. Hematocrit is 52%
ANS: B
All these findings are abnormal; however, only the serum potassium level is
changed to the degree that serious, life-threatening responses could result. With
such a rapid rise in the potassium level, the client is at high risk for
experiencing severe cardiac dysrhythmias and death.

TOP: Nursing Process Step: Assessment/Analysis
20. The client has experienced an electrical injury, with the entrance site
on the left hand and the exit site on the left foot. What are the priority
assessment data to obtain from this client on admission?
A. Airway patency
B. Heart rate and rhythm
C. Orientation to time, place, and person
D. Current range of motion in all extremities
ANS: B
The airway is not at any particular risk with this injury. Electric current
travels through the body from the entrance site to the exit site and can seriously
damage all tissues between the two sites. Early cardiac damage from electrical
injury includes irregular heart rate, rhythm, and ECG changes.

21. In assessing the client's potential for an inhalation injury as a

result of a flame burn, what is the most important question to ask the client on
admission?
A. “Are you a smoker?”
B. “When was your last chest x-ray?”
C. “Have you ever had asthma or any other lung problem?”
D. “In what exact place or space were you when you were burned?”
ANS: D
The risk for inhalation injury is greatest when flame burns occur indoors in
small, poorly ventilated rooms. although smoking increases the risk for some
problems, it does not predispose the client for an inhalation injury.

22. Which information obtained by assessment ensures that the client's

respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client's oxygen saturation is 97%.
D. The client's chest movements are uninhibited
ANS: C
Clients may have ineffective respiratory efforts and gas exchange even though they
are able to talk, have good respiratory movement, and are alert. The best
indicator for respiratory effectiveness is the maintenance of oxygen saturation
within the normal range.
Integrity;
23. Which information obtained by assessment ensures that the client's

respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client's oxygen saturation is 97%.
D. The client's chest movements are uninhibited
ANS: C
Clients may have ineffective respiratory efforts and gas exchange even though they
are able to talk, have good respiratory movement, and are alert. The best
indicator for respiratory effectiveness is the maintenance of oxygen saturation
within the normal range.

Integrity;
24. The burned client's family ask at what point the client will no longer
be at increased risk for infection. What is the nurse’s best response?
A. “When fluid remobilization has started.”
B. “When the burn wounds are closed.”
C. “When IV fluids are discontinued.”
D. “When body weight is normal.”
ANS: B
Intact skin is a major barrier to infection and other disruptions in homeostasis.
No matter how much time has passed since the burn injury, the client remains at
great risk for infection as long as any area of skin is open.

Maintenance;
25. The burned client relates the following history of previous health
problems. Which one should alert the nurse to the need for alteration of the fluid
resuscitation plan?
A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month
ANS: C
It is likely the client has a diminished cardiac output as a result of the old MI
and would be at greater risk for the development of congestive heart failure and
pulmonary edema during fluid resuscitation.

Integrity;
26. The burned client on admission is drooling and having difficulty
swallowing. What is the nurse’s best first action?
A. Assess level of consciousness and pupillary reactions.
B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.
ANS: C
Difficulty swallowing and drooling are indications of oropharyngeal edema and can
precede pulmonary failure. The client’s airway is in severe jeopardy and
intubation is highly likely to be needed shortly.

27. Which intervention is most important for the nurse to use to prevent
infection by cross-contamination in the client who has open burn wounds?
A. Handwashing on entering the client's room
B. Encouraging the client to cough and deep breathe
C. Administering the prescribed tetanus toxoid vaccine
D. Changing gloves between cleansing different burn areas
ANS: A
Cross-contamination occurs when microorganisms from another person or the
environment are transferred to the client. Although all the interventions listed
above can help reduce the risk for infection, only handwashing can prevent cross-
contamination.

28. In reviewing the burned client's laboratory report of white blood cell
count with differential, all the following results are listed. Which laboratory
finding indicates the possibility of sepsis?
A. The total white blood cell count is 9000/mm3.
B. The lymphocytes outnumber the basophils.
C. The “bands” outnumber the “segs.”
D. The monocyte count is 1,800/mm3.
ANS: C
Normally, the mature segmented neutrophils (“segs”) are the major population of
circulating leukocytes, constituting 55% to 70% of the total white blood count.
Fewer than 3% to 5% of the circulating white blood cells should be the less mature
“band” neutrophils. A left shift occurs when the bone marrow releases more
immature neutrophils than mature neutrophils. Such a shift indicates severe
infection or sepsis, in which the client’s immune system cannot keep pace with the
infectious process.

Maintenance;
29. The client has a deep partial-thickness injury to the posterior neck.
Which intervention is most important to use during the acute phase to prevent
contractures associated with this injury?
A. Place a towel roll under the client's neck or shoulder.
B. Keep the client in a supine position without the use of pillows.
C. Have the client turn the head from side to side 90 degrees every hour while
awake.
D. Keep the client in a semi-Fowler’s position and actively raise the arms
above the head every hour while awake.
ANS: C
The function that would be disrupted by a contracture to the posterior neck is
flexion. Moving the head from side to side prevents such a loss of flexion.

MSC: Client Needs Category: Health Promotion and Maintenance/Safe, Effective Care
Environment;
30. The client has severe burns around the right hip. Which position is
most important to be emphasized by the nurse that the client maintain to retain
maximum function of this joint?
A. Hip maintained in 30-degree flexion, no knee flexion
B. Hip flexed 90 degrees and knee flexed 90 degrees
C. Hip, knee, and ankle all at maximum flexion
D. Hip at zero flexion with leg flat
ANS: D
Maximum function for ambulation occurs when the hip and leg are maintained at full
extension with neutral rotation. Although the client does not have to spend 24
hours at a time in this position, he or she should be in this position (in bed or
standing) more of the time than with the hip in any degree of flexion.

Maintenance;
31. During the acute phase, the nurse applied gentamicin sulfate (topical
antibiotic) to the burn before dressing the wound. The client has all the
following manifestations. Which manifestation indicates that the client is having
an adverse reaction to this topical agent?
A. Increased wound pain 30 to 40 minutes after drug application
B. Presence of small, pale pink bumps in the wound beds
C. Decreased white blood cell count
D. Increased serum creatinine level
ANS: D
Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the
wound bed are areas of re-epithelialization and not an adverse reaction.
Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn
wounds to affect kidney function. Any client receiving gentamicin by any route
should have kidney function monitored.

32. The client, who is 2 weeks postburn with a 40% deep partial-thickness
injury, still has open wounds. On taking the morning vital signs, the client is
found to have a below-normal temperature, is hypotensive, and has diarrhea. What
is the nurse’s best action?
A. Nothing, because the findings are normal for clients during the acute phase
of recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client’s airway and oxygen saturation.
D. Notify the burn emergency team.
ANS: D
These findings are associated with systemic gram-negative infection and sepsis.
This is a medical emergency and requires prompt attention.

33. Which intervention is most important to use to prevent infection by

autocontamination in the burned client during the acute phase of recovery?
A. Changing gloves between wound care on different parts of the client's body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.
ANS: A
Autocontamination is the transfer of microorganisms from one area to another area
of the same client's body, causing infection of a previously uninfected area.
Although all techniques listed can help reduce the risk for infection, only
changing gloves between carrying out wound care on difference parts of the
client’s body can prevent autocontamination.

Integrity;
34. When should ambulation be initiated in the client who has sustained a
major burn?
A. When all full-thickness areas have been closed with skin grafts
B. When the client's temperature has remained normal for 24 hours
C. As soon as possible after wound debridement is complete
D. As soon as possible after resolution of the fluid shift
ANS: D
Regular, progressive ambulation is initiated for all burn clients who do not have
contraindicating concomitant injuries as soon as the fluid shift resolves. Clients
can be ambulated with extensive dressings, open wounds, and nearly any type of
attached lines, tubing, and other equipment.

Maintenance;
35. What statement by the client indicates the need for further discussion
regarding the outcome of skin grafting (allografting) procedures?
A. “For the first few days after surgery, the donor sites will be painful.”
B. “Because the graft is my own skin, there is no chance it won't 'take'.”
C. “I will have some scarring in the area when the skin is removed for
grafting.”
D. “Once all grafting is completed, my risk for infection is the same as it was
before I was burned.”
ANS: B
Factors other than tissue type, such as circulation and infection, influence
whether and how well a graft “takes.” The client should be prepared for the
possibility that not all grafting procedures will be successful.

MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial
Integrity
36. Which statement by the client indicates correct understanding of

rehabilitation after burn injury?
A. “I will never be fully recovered from the burn.”
B. “I am considered fully recovered when all the wounds are closed.”
C. “I will be fully recovered when I am able to perform all the activities I
did before my injury.”
D. “I will be fully recovered when I achieve the highest possible level of
functioning that I can.”
ANS: D
Although a return to preburn functional levels is rarely possible, burned clients
are considered fully recovered or rehabilitated when they have achieved their
highest possible level of physical, social, and emotional functioning.

MSC: Client Needs Category: Psychosocial Integrity
37. Which statement made by the client with facial burns who has been
prescribed to wear a facial mask pressure garment indicates correct understanding
of the purpose of this treatment?
A. “After this treatment, my ears will not stick out.”
B. “The mask will help protect my skin from sun damage.”
C. “Using this mask will prevent scars from being permanent.”
D. “My facial scars should be less severe with the use of this mask.”
ANS: D
The purpose of wearing the pressure garment over burn injuries for up to 1 year is
to prevent hypertrophic scarring and contractures from forming. Scars will still
be present. Although the mask does provide protection of sensitive newly healed
skin and grafts from sun exposure, this is not the purpose of wearing the mask.
The pressure garment will not change the angle of ear attachment to the head.

MSC: Client Needs Category: Psychosocial Integrity/Health Promotion and
Maintenance
38. What is the priority nursing diagnosis for a client in the

rehabilitative phase of recovery from a burn injury?
A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements
ANS: B
Recovery from a burn injury requires a lot of work on the part of the client and
significant others. Seldom is the client restored to the preburn level of
functioning. Adjustments to changes in appearance, family structure, employment
opportunities, role, and functional limitations are only a few of the numerous
life-changing alterations that must be made or overcome by the client. By the
rehabilitation phase, acute pain from the injury or its treatment is no longer a
problem.

TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Psychosocial Integrity
SHORT ANSWER
1. The client, who weighs 90 kg and had a 50% burn injury at 10 AM,
arrives at the hospital at noon. He is prescribed to need 18,000 mL of fluid
during the first 24 hours after his injury. Using the Parkland formula, calculate
the rate the nurse should use to deliver the fluid when the IV is started at noon.
ANS:
1500 mL/hour
Rationale: The Parkland formula states that the client should receive half of the
calculated fluid replacement during the first 8 hours after injury and half during
the next 16 hours. This client was burned at 10 AM and fluid was not started until
noon. Therefore, the 9000 mL must be infused in the next 6 hours at 1500 mL/ hour
to meet the criteria of receiving half the calculated dose in the first 8 hours
postburn.

MSC: Client Needs Category: Physiological Integrity

Nursing Care For Burns

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Interventions for Clients with Burns

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

3. The burned client newly arrived from an accident scene is prescribed to

4. Which vitamin deficiency is most likely to be a long-term consequence

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A

5. Which client factors should alert the nurse to potential increased

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment

6. The burned client is ordered to receive intravenous cimetidine, an H2

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment

8. What clinical manifestation should alert the nurse to possible carbon

DIF: Cognitive Level: Application or higher

9. What clinical manifestation indicates that an escharotomy is needed on

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Evaluation

10. What additional laboratory test should be performed on any African

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment

DIF: Cognitive Level: Comprehension

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

15. On admission to the emergency department the burned client's blood

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

21. In assessing the client's potential for an inhalation injury as a

DIF: Cognitive Level: Application or higher

22. Which information obtained by assessment ensures that the client's

23. Which information obtained by assessment ensures that the client's

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Comprehension

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

33. Which intervention is most important to use to prevent infection by

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Comprehension

DIF: Cognitive Level: Application or higher

36. Which statement by the client indicates correct understanding of

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

38. What is the priority nursing diagnosis for a client in the

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

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