Nokea
A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?
- A. To prevent neuropathies
- B. To prevent wound breakdown
- C. To prevent contractures
- D. To prevent heterotopic ossification
Correct Answer: C
Rationale: Maintaining joint alignment prevents contractures, a common complication of burns due to tissue shortening. It does not primarily prevent neuropathies, wound breakdown, or ossification.
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An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patients body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?
- A. Administer IV fluids
- B. Administer broad-spectrum antibiotics
- C. Administer IV potassium chloride
- D. Administer packed red blood cells
Correct Answer: A
Rationale: IV fluid administration is critical to address massive fluid losses and prevent hypovolemic shock in the initial burn-shock period. Antibiotics, potassium, or PRBCs are not immediate priorities.
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 burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?
- A. Thats something that you and your doctor will likely talk about after your scars mature.
- B. That is something for you to talk to your doctor about because its not a nursing responsibility.
- C. I know this is really important to you, but you have to realize that no one can make you look like you used to.
- D. Unfortunately, its likely that you will have most of these scars for the rest of your life.
Correct Answer: A
Rationale: Reconstructive surgery is considered after scars mature, typically within 1-2 years, making this an appropriate, hopeful response. Other options dismiss the patient's concern or lack empathy.
The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care?
- A. Emergent
- B. Immediate resuscitative
- C. Acute
- D. Rehabilitation
Correct Answer: C
Rationale: The acute phase, starting 48-72 hours post-burn, focuses on wound care, infection prevention, and nutritional support. The emergent phase prioritizes fluid resuscitation and airway management, immediate resuscitative is not a distinct phase, and rehabilitation focuses on scar prevention and psychosocial support.
A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do?
- A. Cover the burn with ice and secure with a towel.
- B. Apply butter to the area that is burned.
- C. Immerse the child in a cool bath.
- D. Avoid touching the burned area under any circumstances.
Correct Answer: C
Rationale: Immersing the burn in cool water halts the burning process and relieves pain. Ice can cause hypothermia, butter traps heat, and avoiding all contact prevents necessary first aid.