Nokea
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.
You may also like to solve these questions
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.
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.
A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
- A. 4 to 6 hours a day for 6 months
- B. During waking hours for 2 to 3 months after the injury
- C. Continuously
- D. At night while sleeping for a year after the injury
Correct Answer: C
Rationale: Elastic pressure garments should be worn continuously (23 hours/day) to minimize scarring and contractures, typically for months until scars mature.
A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?
- A. 2 days
- B. 3 days
- C. 5 days
- D. 1 week
Correct Answer: A
Rationale: Upper airway edema from burns can develop up to 48 hours post-injury due to inflammation and fluid shifts, requiring vigilant monitoring. Later onset is less likely.
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.