Nokea
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.
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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 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 with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock?
- A. Confusion
- B. High fever
- C. Decreased blood pressure
- D. Sudden agitation
Correct Answer: C
Rationale: Decreased blood pressure signals burn shock onset due to reduced vascular volume from fluid loss. Confusion, fever, or agitation are not primary indicators.
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.