Nokea
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.
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A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurses most appropriate intervention?
- A. Reinforce the Biobrane dressing with another piece of Biobrane.
- B. Remove the Biobrane dressing and apply a new dressing.
- C. Trim away the separated Biobrane.
- D. Notify the physician for further emergency-related orders.
Correct Answer: C
Rationale: As Biobrane separates naturally from a healing wound, trimming the loose edges is appropriate, leaving the adhered portion intact. Reinforcing, replacing, or notifying the physician is unnecessary.
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 patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care?
- A. Fluid status
- B. Risk of infection
- C. Nutritional status
- D. Psychosocial coping
Correct Answer: A
Rationale: Fluid resuscitation is the immediate priority post-cardiopulmonary stabilization to address massive fluid losses through damaged skin, preventing hypovolemic shock. Infection, nutrition, and coping are addressed later.
A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation?
- A. Pain
- B. Fluid balance
- C. Anxiety and fear
- D. Airway management
Correct Answer: D
Rationale: Airway management is the priority due to the risk of obstruction from smoke inhalation-induced edema, following the ABCs of trauma care. Pain, fluid balance, and anxiety are secondary.
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.