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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.
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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 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.
An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?
- A. The causative agent
- B. The patients preinjury health status
- C. The patients prognosis for recovery
- D. The circumstances of the accident
Correct Answer: A
Rationale: Burn depth is determined by factors like the causative agent (e.g., scalding liquid), temperature, contact duration, and skin thickness. Preinjury health, prognosis, and accident circumstances are not direct determinants.
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 received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patients body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?
- A. Administer IV fluids
- B. Administer broad-spectrum antibiotics
- C. Administer IV potassium chloride
- D. Administer packed red blood cells
Correct Answer: A
Rationale: IV fluid administration is critical to address massive fluid losses and prevent hypovolemic shock in the initial burn-shock period. Antibiotics, potassium, or PRBCs are not immediate priorities.