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The nurse is admitting a patient to the burn unit who has an approximate 25% total body surface area (TBSA) burn and the following initial laboratory results: Hct 56%, Hb 172 g.L., serum K+ 4.8 mmol.L., and serum Na+ 135 mmol.L. Which of the following actions should the nurse anticipate implementing?
- A. Continue to monitor the laboratory results
- B. Increase the rate of the ordered IV solution.
- C. Type and crossmatch for a blood transfusion.
- D. Document the findings in the patient's record.
Correct Answer: B
Rationale: The patient's laboratory data show hemconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase.
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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.
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.
The staff nurse is supervising a student nurse on the burn unit. Which of the following actions by the student nurse require that the staff nurse intervene?
- A. The student nurse uses clean latex gloves when applying antibacterial cream to a burn wound.
- B. The student nurse obtains burn cultures when the patient has a temperature of 35.1.C (95.1.F).
- C. The student nurse administers PRN fentanyl IV to a patient 5 minutes before a dressing change
- D. The student nurse calls the health care provider for an insulin order when a nondiabetic patient has an elevated serum glucose.
Correct Answer: A
Rationale: Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.
The nurse is caring for a patient who has circumferential burns of both arms and develops a decrease in radial pulse strength and numbness in the fingers. Which of the following actions should the nurse take?
- A. Notify the health care provider.
- B. Monitor the pulses every 2 hours.
- C. Elevate both arms above heart level with pillows.
- D. Encourage the patient to flex and extend the fingers.
Correct Answer: A
Rationale: The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the arms and the need for escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the hands or increasing hand movement will not improve the patient's circulation.
The nurse is admitting a patient with extensive electrical burn injuries. Which of the following prescribed interventions should the nurse implement first?
- A. Start two large bore IVs.
- B. Place on cardiac monitor.
- C. Apply dressings to burned areas.
- D. Assess for pain at contact points.
Correct Answer: B
Rationale: After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start two IVs, assess for pain, and apply dressings.