Nokea
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
- A. Instruct the patient to keep the wound site in a dependent position.
- B. Administer PRN analgesia as ordered.
- C. Assess the patients peripheral pulses distal to the dressing.
- D. Assist with passive range of motion exercises to set the new dressing.
Correct Answer: C
Rationale: Checking peripheral pulses ensures dressings are not too tight, preventing circulatory compromise. Dependent positioning is avoided, analgesia is given before dressing changes, and ROM exercises are not typically post-dressing.
You may also like to solve these questions
A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?
- A. Monitoring fluid and electrolyte imbalances
- B. Providing education to the patient and family
- C. Treating infection
- D. Promoting thermoregulation
Correct Answer: B
Rationale: Education for the patient and family is a priority in the rehabilitation phase to support self-care and adjustment. Fluid imbalances, infection, and thermoregulation are addressed in the acute phase.
A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response?
- A. Perform mechanical debridement to remove the exudate and prevent further infection.
- B. Inform the primary care provider promptly because the graft may need to be removed.
- C. Perform range of motion exercises to increase perfusion to the graft site and facilitate healing.
- D. Document this finding as an expected phase of graft healing.
Correct Answer: B
Rationale: Purulent exudate indicates possible graft infection, necessitating prompt provider notification for potential graft removal. Debridement or exercises are inappropriate, and infection is not an expected healing phase.
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 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.
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.