Nokea
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?
- A. Sodium deficit
- B. Decreased prothrombin time (PT)
- C. Potassium deficit
- D. Decreased hematocrit
Correct Answer: A
Rationale: Sodium deficit (hyponatremia) occurs in the emergent phase due to sodium loss in edema fluid. Potassium is elevated, hematocrit increases, and PT is not typically decreased.
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A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response?
- A. Perform mechanical debridement to remove the exudate and prevent further infection.
- B. Inform the primary care provider promptly because the graft may need to be removed.
- C. Perform range of motion exercises to increase perfusion to the graft site and facilitate healing.
- D. Document this finding as an expected phase of graft healing.
Correct Answer: B
Rationale: Purulent exudate indicates possible graft infection, necessitating prompt provider notification for potential graft removal. Debridement or exercises are inappropriate, and infection is not an expected healing phase.
A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what?
- A. Hemodynamic instability
- B. Gastrointestinal hypermotility
- C. Respiratory arrest
- D. Hypokalemia
Correct Answer: A
Rationale: Hemodynamic instability occurs first due to capillary leakage, causing fluid shifts and hypovolemia. GI hypermotility, respiratory arrest, or hypokalemia are not initial events.
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication?
- A. Ischemia
- B. Referred pain
- C. Cellulitis
- D. Venous thromboembolism (VTE)
Correct Answer: A
Rationale: Circumferential burns can cause edema, compressing blood vessels and leading to distal ischemia, similar to compartment syndrome. Referred pain, cellulitis, or VTE are less immediate concerns.
A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
- A. Activity Intolerance
- B. Anxiety
- C. Ineffective Coping
- D. Acute Pain
Correct Answer: D
Rationale: Acute pain is a priority in deep partial-thickness burns due to its severity, impacting recovery and contributing to anxiety or coping issues. Pain management often precedes addressing other diagnoses.
A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock?
- A. Confusion
- B. High fever
- C. Decreased blood pressure
- D. Sudden agitation
Correct Answer: C
Rationale: Decreased blood pressure signals burn shock onset due to reduced vascular volume from fluid loss. Confusion, fever, or agitation are not primary indicators.