Nokea
A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?
- A. Obtain an order to reduce the rate of the patients IV fluid infusion.
- B. Report the patients early signs of acute kidney injury (AKI).
- C. Recognize that the patient is experiencing an expected onset of diuresis.
- D. Administer sodium chloride as ordered to compensate for this fluid loss.
Correct Answer: C
Rationale: Increased urine output 72 hours post-burn indicates the onset of diuresis as capillaries regain integrity, shifting fluid back to the intravascular space. This is expected, not indicative of AKI or requiring fluid reduction or sodium administration.
You may also like to solve these questions
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 has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
- A. Early enteral feeding
- B. Administration of prophylactic antibiotics
- C. Bowel cleansing procedures
- D. Administration of stool softeners
Correct Answer: A
Rationale: Early enteral feeding supports the intestinal mucosal barrier, reducing permeability and preventing endotoxin translocation. Prophylactic antibiotics risk resistant bacteria, and bowel cleansing or stool softeners do not address this issue.
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 patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what?
- A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
- B. Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis
- C. Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis
- D. Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
Correct Answer: A
Rationale: In the emergent phase, cell damage releases potassium (hyperkalemia), sodium is lost to edema (hyponatremia), hemoconcentration increases hematocrit, and tissue hypoxia causes metabolic acidosis. Other combinations do not align with burn pathophysiology.
An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?
- A. The causative agent
- B. The patients preinjury health status
- C. The patients prognosis for recovery
- D. The circumstances of the accident
Correct Answer: A
Rationale: Burn depth is determined by factors like the causative agent (e.g., scalding liquid), temperature, contact duration, and skin thickness. Preinjury health, prognosis, and accident circumstances are not direct determinants.