Nokea
A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?
- A. Maintenance of bed rest to aid healing
- B. Choosing appropriate splints and functional devices
- C. Administration of beta adrenergic blockers
- D. Prevention of venous thromboembolism
Correct Answer: D
Rationale: Preventing venous thromboembolism is crucial in the acute phase due to immobility and hypercoagulability. Bed rest is avoided, splints are chosen by therapists, and beta blockers are not standard.
You may also like to solve these questions
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications?
- A. A 4-year-old scald victim burned over 24% of the body
- B. A 27-year-old male burned over 36% of his body in a car accident
- C. A 39-year-old female patient burned over 18% of her body
- D. A 60-year-old male burned over 16% of his body in a brush fire
Correct Answer: A
Rationale: Young children, like the 4-year-old, have higher morbidity and mortality risk due to physiological immaturity, making their burns more life-threatening despite smaller TBSA compared to adults.
A patients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?
- A. 0.45% NaCl with 20 mEq/L KCl
- B. 0.45% NaCl with 40 mEq/L KCl
- C. Normal saline
- D. Lactated Ringers
Correct Answer: D
Rationale: Lactated Ringers is the preferred fluid for burn resuscitation, closely matching plasma osmolality and avoiding hyperchloremic acidosis associated with normal saline. Potassium-containing fluids risk worsening hyperkalemia.
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.
A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?
- A. Apply the new ointment without disturbing the existing layer of ointment.
- B. Apply the ointment using a sterile tongue depressor.
- C. Apply a layer of ointment approximately 1/16 inch thick.
- D. Gently irrigate the wound bed after applying the antibiotic ointment.
Correct Answer: C
Rationale: A 1/16-inch layer of topical antibiotic ointment, applied with clean gloves after removing old ointment, ensures effective coverage. Old ointment is removed, tongue depressors are not standard, and irrigation follows application.
A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have?
- A. 13%
- B. 25%
- C. 9%
- D. 18%
Correct Answer: D
Rationale: Using the Rule of Nines, the face accounts for 9% and the left forearm 9%, totaling 18% TBSA.