Nokea
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.
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Which of the following actions should the nurse take first when a patient arrives in the emergency department with facial and chest burns caused by a house fire?
- A. Infuse the ordered IV solution.
- B. Ausculate the patient's lung sounds.
- C. Determine the extent and depth of the burns.
- D. Administer the ordered opioid pain medications.
Correct Answer: B
Rationale: A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.
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.
Which of the following assessment parameters is the priority nursing assessment when caring for a patient who has just arrived in the emergency department after suffering an electrical burn from exposure to a high-voltage current?
- A. Oral temperature
- B. Peripheral pulses
- C. Extremity movement
- D. Pupil reaction to light
Correct Answer: C
Rationale: All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data also are necessary but not as essential as determining cervical spine status.
The nurse is caring for a patient with severe burns who is receiving crystalloid fluid replacement IV. ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30000 ml. The initial rate of administration is 1875 ml/hour. Which of the following infusion rates is accurate after the first 8 hours?
- A. 350 ml/hour
- B. 253 ml/hour
- C. 938 ml/hour
- D. 250 ml/hour
Correct Answer: C
Rationale: Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours (25% per each 8 hour period, respectively). In this case, the patient should receive half of the initial rate, or 938 ml/hour.
The nurse is caring for a patient who has burns on the back and chest from a house fire and has become agitated and restless 9 hours after being admitted to the hospital. Which of the following actions should the nurse take first?
- A. Stay at the bedside and reassure the patient.
- B. Administer the ordered morphine sulphate IV.
- C. Assess orientation and level of consciousness.
- D. Use pulse oximetry to check the oxygen saturation.
Correct Answer: D
Rationale: Agitation in a patient who may have suffered inhalation injury might flanks hypoxemia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation also is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.