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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.
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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 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 burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?
- A. Thats something that you and your doctor will likely talk about after your scars mature.
- B. That is something for you to talk to your doctor about because its not a nursing responsibility.
- C. I know this is really important to you, but you have to realize that no one can make you look like you used to.
- D. Unfortunately, its likely that you will have most of these scars for the rest of your life.
Correct Answer: A
Rationale: Reconstructive surgery is considered after scars mature, typically within 1-2 years, making this an appropriate, hopeful response. Other options dismiss the patient's concern or lack empathy.
A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?
- A. Monitoring fluid and electrolyte imbalances
- B. Providing education to the patient and family
- C. Treating infection
- D. Promoting thermoregulation
Correct Answer: B
Rationale: Education for the patient and family is a priority in the rehabilitation phase to support self-care and adjustment. Fluid imbalances, infection, and thermoregulation are addressed in the acute phase.
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.