Nokea
In which order should the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's back?
- A. Apply sterile gauze dressing.
- B. Document wound appearance.
- C. Apply silver sulphadiazine cream.
- D. Administer IV fentanyl.
- E. Clean wound with saline-soaked gauze.
Correct Answer: D,E,C,A,B
Rationale: Since partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.
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The nurse is caring for a patient who is in the emergent phase of burn care. Which of the following nursing actions will be most useful in determining whether the patient is receiving adequate fluid infusion?
- A. Check skin turgor.
- B. Monitor daily weight.
- C. Assess mucous membranes.
- D. Measure hourly urine output.
Correct Answer: D
Rationale: When fluid intake is adequate, the urine output will be at least 0.5-1 ml/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.
Which of the following nursing actions should be done first for a patient who has suffered a burn injury while working on an electrical power line?
- A. Obtain the blood pressure.
- B. Stabilize the cervical spine.
- C. Assess for the contact points.
- D. Check alertness and orientation.
Correct Answer: B
Rationale: Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions also are included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.
The nurse is caring for a patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns and has a nursing diagnosis of disturbed body image. Which of the following actions by the patient indicates that the problem is resolving?
- A. Staring that the scarring will only be temporary
- B. Avoiding using a pillow to prevent neck contractures
- C. Asking about how to use make-up to cover up the scars
- D. Expressing sadness and anger about the scar appearance
Correct Answer: C
Rationale: The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.
The nurse is caring for a patient who has deep partial-thickness and full-thickness burns of the face and chest and is having the wounds treated with the open method. Which of the following nursing actions should be included in the plan of care?
- A. Restritct all visitors to prevent cross-contamination of wounds.
- B. Wear gowns, caps, masks, and gloves during all care of the patient.
- C. Turn the room temperature up to at least 20 C (68 F) during dressing changes.
- D. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.
Correct Answer: B
Rationale: Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. Restricting all visitors is not necessary and will have adverse psychosocial consequences for the patient. The room temperature should be kept at approximately 30 C (86 F) for patients with open burn wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.
The nurse is caring for a patient who has burns on the back and chest from a house fire and has become agitated and restless 9 hours after being admitted to the hospital. Which of the following actions should the nurse take first?
- A. Stay at the bedside and reassure the patient.
- B. Administer the ordered morphine sulphate IV.
- C. Assess orientation and level of consciousness.
- D. Use pulse oximetry to check the oxygen saturation.
Correct Answer: D
Rationale: Agitation in a patient who may have suffered inhalation injury might flanks hypoxemia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation also is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.