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


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.

Nursing

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The nurse assesses a client's oral cavity and makes the discovery shown in the photo below:

What action by the nurse is most appropriate? a. Encourage the client to have genetic testing. b. Instruct the client on high-fiber foods. c. Place the client in protective precautions. d. Teach the client about cobalamin therapy.

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The nurse prepares to examine a young adult's tympanic membrane. To straighten the ear canal, in which direction should the pinna be pulled?

a. down and back c. up and forward b. down and forward d. up and back

Nursing

In which muscle should the nurse select to give a 6-month-old infant an intramuscular injection?

a. Deltoid b. Ventrogluteal c. Dorsogluteal d. Vastus lateralis

Nursing

The brother of a terminally ill patient states, "I'll donate a million dollars to the hospital if they cure my brother." The nurse realizes this statement indicates which phase of Kübler-Ross's stages of loss?

1. bargaining 2. denial 3. anger 4. acceptance

Nursing