Nokea
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.
You may also like to solve these questions
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 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.
The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk?
- A. Apply skin emollients as ordered after granulation has occurred.
- B. Keep injured areas immobilized whenever possible to promote healing.
- C. Administer oral or IV corticosteroids as ordered.
- D. Encourage physical activity and range of motion exercises.
Correct Answer: D
Rationale: Physical activity and range of motion exercises prevent contractures and hypertrophic scarring by maintaining joint mobility and reducing tissue shortening. Emollients and immobilization are not standard, and corticosteroids slow healing.
An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
- A. The length of time since the burn
- B. The location of burned skin surfaces
- C. The source of the burn
- D. The total body surface area (TBSA) affected by the burn
Correct Answer: D
Rationale: TBSA is the primary determinant of systemic response, as larger burns cause greater fluid loss, metabolic demand, and organ stress. Time, location, and source are secondary factors.
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.