Nokea
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.
You may also like to solve these questions
A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurses most appropriate intervention?
- A. Reinforce the Biobrane dressing with another piece of Biobrane.
- B. Remove the Biobrane dressing and apply a new dressing.
- C. Trim away the separated Biobrane.
- D. Notify the physician for further emergency-related orders.
Correct Answer: C
Rationale: As Biobrane separates naturally from a healing wound, trimming the loose edges is appropriate, leaving the adhered portion intact. Reinforcing, replacing, or notifying the physician is unnecessary.
A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?
- A. Maintenance of bed rest to aid healing
- B. Choosing appropriate splints and functional devices
- C. Administration of beta adrenergic blockers
- D. Prevention of venous thromboembolism
Correct Answer: D
Rationale: Preventing venous thromboembolism is crucial in the acute phase due to immobility and hypercoagulability. Bed rest is avoided, splints are chosen by therapists, and beta blockers are not standard.
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.
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.
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.