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Six hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse obtains these data when assessing a patient who weighs 55 kg. Which of the following information is priority for the nurse to communicate to the health care provider?
- A. Blood pressure is 94/46 per arterial line.
- B. Serous exudate is leaking from the burns.
- C. Cardiac monitor shows a pulse rate of 104.
- D. Urine output is 20 mL/hour for the past 2 hours.
Correct Answer: D
Rationale: The urine output should be at least 0.5-1.0 mL/kg/hour during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.
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After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
- B. A patient with smoke inhalation who has wheezes and altered mental status
- C. A patient with full-thickness leg burns who has a dressing change scheduled
- D. A patient with abdominal burns who is complaining of level 8 (0-10 scale) pain
Correct Answer: B
Rationale: This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine need for oxygen or intubation. The other patients also should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.
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 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.
Which of the following actions should be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand?
- A. Place the right arm and hand flexed in a position of comfort.
- B. Elevate the right arm and hand on pillows and extend the fingers.
- C. Assist the patient to a supine position with a small pillow under the head.
- D. Position the patient in a side-lying position with rolled towel under the neck.
Correct Answer: B
Rationale: The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow since this will put pressure on the ears and may stick to the ears. Patients with neck burns should not use a pillow, since the head should be maintained in an extended position in order to avoid contractures.
The nurse is caring for a patient who has partial-thickness burns. Which of the following prescribed medications will be best for the nurse to use before wound debridement?
- A. Ketorolac
- B. Lorazepam
- C. Gabapentin
- D. Hydromorphone
Correct Answer: D
Rationale: Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effect of opioids.