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The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care?
- A. Emergent
- B. Immediate resuscitative
- C. Acute
- D. Rehabilitation
Correct Answer: C
Rationale: The acute phase, starting 48-72 hours post-burn, focuses on wound care, infection prevention, and nutritional support. The emergent phase prioritizes fluid resuscitation and airway management, immediate resuscitative is not a distinct phase, and rehabilitation focuses on scar prevention and psychosocial support.
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A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?
- A. Apply the new ointment without disturbing the existing layer of ointment.
- B. Apply the ointment using a sterile tongue depressor.
- C. Apply a layer of ointment approximately 1/16 inch thick.
- D. Gently irrigate the wound bed after applying the antibiotic ointment.
Correct Answer: C
Rationale: A 1/16-inch layer of topical antibiotic ointment, applied with clean gloves after removing old ointment, ensures effective coverage. Old ointment is removed, tongue depressors are not standard, and irrigation follows application.
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.
While performing a patients ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patients behavior?
- A. The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior.
- B. The patient may be experiencing neurologic or psychiatric complications of his injuries.
- C. The patient may be experiencing inconsistencies in the care that he is being provided.
- D. The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.
Correct Answer: D
Rationale: Anger is common in burn patients and may be deflected toward caregivers. Drug reactions, complications, or care inconsistencies are less likely without specific evidence.
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.
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
- A. Instruct the patient to keep the wound site in a dependent position.
- B. Administer PRN analgesia as ordered.
- C. Assess the patients peripheral pulses distal to the dressing.
- D. Assist with passive range of motion exercises to set the new dressing.
Correct Answer: C
Rationale: Checking peripheral pulses ensures dressings are not too tight, preventing circulatory compromise. Dependent positioning is avoided, analgesia is given before dressing changes, and ROM exercises are not typically post-dressing.