Nokea
The nurse is admitting a patient to the burn unit who has burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. Which of the following actions should the nurse implement first?
- A. Encourage the patient to cough and ausculate the lungs again.
- B. Notify the health care provider and prepare for endotracheal intubation.
- C. Document the results and continue to monitor the patient's respiratory rate.
- D. Reposition the patient in high-Fowler's position and reassess breath sounds.
Correct Answer: B
Rationale: The patient's history and clinical manifestations suggest airway edema and the health care provider should immediately be notified so that intubation can rapidly be done. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.
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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.
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 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.
Which of the following laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago?
- A. Hct 52%
- B. BUN 13.8 mmol/L.
- C. Serum sodium 146 mmol/L.
- D. Serum potassium 6.2 mmol/L.
Correct Answer: D
Rationale: Hyperkalemia can lead to fatal bradycardia and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values also are abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.
The nurse is assessing a patient who spilled hot oil on the right leg and foot and notes that the skin is red, swollen, and covered with large blisters. The patient states that they are very painful. Which of the following bum descriptions should the nurse document?
- A. Full-thickness skin destruction
- B. Deep full-thickness skin destruction
- C. Deep partial-thickness skin destruction
- D. Superficial partial-thickness skin destruction
Correct Answer: C
Rationale: The erythema, swelling, and blisters point to a deep partial-thickness burn. With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial-thickness burns, the area is red, but no blisters are present.