Nokea
The nurse assisting with data collection of a burned patient upon arrival in the emergency room observes that the entire right arm (anterior and posterior), right anterior leg, chest, and abdomen are covered with reddened skin and blisters. Using the Rule of Nines, the nurse estimates the percentage of burn to be %.
- A. 36
Correct Answer: 36
Rationale: Anterior and posterior are 9%, anterior leg = 9%, chest = 9%, abdomen = 9%. Total 36%.
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Which patient statement indicates that more teaching is needed regarding antibiotic therapy for the treatment of cellulitis?
- A. My skin is cleared up. I don't think I need the medication anymore.'
- B. Cellulitis can come back at any time.'
- C. If I had washed that scratch with soap and water, I probably would not have gotten cellulitis.'
- D. Cellulitis is contagious.'
Correct Answer: A
Rationale: The entire amount of antibiotic medication should be completed even if the symptoms have abated to ensure the eradication of the infectious agent. Cellulitis can return if untreated or undertreated. Washing wounds with soap and water can prevent many infections, but this is not related to the discussion of antibiotics. Cellulitis can spread, however this is not related to the discussion of antibiotics.
During primary survey of a patient who sustained a burn injury, the nurse checks for which as an early signs of carbon monoxide poisoning?
- A. Dizziness
- B. Urticaria
- C. Vomiting
- D. Headache
- E. Vertigo
- F. Unsteady gait
Correct Answer: C,D,F
Rationale: Early signs of carbon monoxide poisoning include headache, nausea, vomiting, and unsteady gait. Urticaria is a skin reaction seen in allergic responses. Dizziness and vertigo are not signs of carbon monoxide poisoning.
A patient who has sustained a burn injury will undergo wound debridement. The nurse includes which explanation when explaining the purpose of burn wound debridement?
- A. To increase the effectiveness of the skin graft.
- B. Prevention of infection and promote healing.
- C. Promoting suppuration of the wound.
- D. Promoting movement in the affected area.
Correct Answer: B
Rationale: Débridement is the removal of damaged tissue and cellular debris from a wound or burn to prevent infection and to promote healing. Debridement does not increase the effectiveness of the skin graft, promote wound suppuration or movement.
Which instruction will the nurse give the patient taking isotretinoin to treat acne?
- A. Do not take acetaminophen when using this medication.
- B. This medication may cause dry skin or eczema to develop
- C. Wear heavy makeup to cover up the acne until this medication takes effect
- D. Stay away from school or your friends until this medication begins to take effect.
Correct Answer: B
Rationale: Isotretinoin may cause dry skin or eczema to develop. There is no reason to avoid acetaminophen when using this medication. Heavy makeup is not advised. The nurse should provide emotional support to the patient with acne so the patient can continue their lifestyle.
What is the last intervention for a hospitalized severely burned victim during the emergent phase?
- A. Tetanus prophylaxis.
- B. Insert Foley catheter.
- C. Insert nasogastric tube.
- D. Establish airway.
- E. Administer analgesics.
- F. Initiate fluid therapy.
Correct Answer: A,
Rationale: The priority of care should proceed from the establishment of an airway,initiation of fluid therapy,insertion of Foley and NG tube administration of analgesics and tetanus prophylaxis."