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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.
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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 public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort?
- A. Education about home safety
- B. Education about safe storage of chemicals
- C. Education about workplace health threats
- D. Education about safe driving
Correct Answer: A
Rationale: Most burns occur at home, making home safety education (e.g., scald prevention, fire safety) the most relevant health promotion effort based on epidemiological data.
A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.
- A. Promote truthful communication.
- B. Avoid asking the patient to make decisions.
- C. Teach the patient coping strategies.
- D. Administer benzodiazepines as ordered.
- E. Provide positive reinforcement.
Correct Answer: A,C,E
Rationale: Promoting truthful communication, teaching coping strategies, and providing positive reinforcement foster effective coping by building trust and skills. Decision-making supports autonomy, and benzodiazepines address anxiety, not coping.
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.
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.